Every finding on record at St George Healthcare Center

Based on observation, interview, and facility policy review, the facility failed to keep the kitchen's large manual can opener, a kitchen oven, stove top spill pan, and four kitchen drawers which had food preparation and service equipment stored inside clean. These failures had the potential to create an environment for food-borne illnesses which could affect 80 residents who consumed food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled, Sanitation & Food Safety in Food and Nutrition Services, dated 10/15/25, specified, . Policy: The Certified Dietary Manager (CDM) will assume responsibility for the food safety and sanitation of the Nutrition Culinary Department. Procedures: 1. Infection control and sanitation practices are followed to minimize the risk of contamination of food and prevent food borne illness . 4. The CDM monitors food safety and sanitation of the Food and Nutrition Department daily. 5. The CDM develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals .1. Observation during the initial kitchen inspection on 02/15/26 from 8:25 AM to 8:50 AM, revealed the following unclean food preparation and service equipment that was stored and ready for use: a. The kitchen's large manual can opener was unclean with dried and sticky substances on its blade and table base attachment. b. A kitchen oven was unclean with accumulated dried and burned food spills in its inner cooking compartment.c. The kitchen's stove top spill pan was unclean with a heavy accumulation of dried food and burned food spills.d. The inner storage compartments of four kitchen drawers which had food preparation and service equipment stored in them including serving scoops, serving spoons, spatulas, ladles, tongs, adaptive eating utensils, and measuring cups were unclean with accumulated dried substances and loose food debris.During observation on 02/15/26 from 8:50 AM to 9:00 AM, the Dietary Manager (DM) was shown the above unclean kitchen equipment, and she confirmed the four kitchen drawers which housed food preparation and service equipment, the kitchen oven, the stove top's spill pan, and the kitchen's large manual can opener's blade and its table base attachment were unclean. During an interview on 02/15/26 at 9:00 AM, the DM stated the kitchen's drawers, kitchen oven, and stove top spill pan should be cleaned by staff weekly or as needed. The DM also stated the kitchen's large manual can opener, and its table base attachment should be cleaned after each use.

Based on observation, record review, staff interviews, and policy review, the facility failed to implement processes to ensure: 1. staff verified and signed that the controlled substance count was correct at each shift change in the narcotic count books, and 2. controlled medications were maintained in a safe and secure manner to prevent loss or diversion. These failures were identified in four of four medication carts ([NAME] Unit - Medication Carts #1 and #2; Stone Unit - Medication Carts #1 and #2) observed for medication storage and labeling. This deficient practice created the potential for drug diversion, medication theft, and improper handling of controlled substance returns, which could impact patient safety and the facility's compliance with medication management requirements.Findings include:Review of the facility policy Section 2 - Controlled Substances, revised 04/17/2024, revealed, Policy: 1. The Facility will have systems in place to ensure the safe and secure storage of controlled substance medications. 2. The Facility will conduct routine reconciliations of all Controlled Substances to prevent any potential loss or diversion. Procedures: 4. A scheduled reconciliation (shift change count) of controlled substance inventory should be completed at every nursing shift change and documented as required by state regulations. H. Both staff members (off going and oncoming) sign the Controlled Substance Shift Change Sheet with the date and time of the shift change. K. In counting Controlled Substance drugs, the nurse/authorized staff member is alert for any evidence of a substitution or tampering by closely inspecting all tablets, solutions, and packages. If the oncoming nurse/authorized staff member, notices any defects in a drug container or products, they shall immediately report any suspicion of substitution or tampering with controlled drugs to the Director of Nursing.1. During an observation on 02/15/26 at 10:38 AM of Medication Cart #1 on [NAME] Unit with Licensed Practical Nurse (LPN)1, it was revealed the shift change sheet of controlled substance inventory was missing the signature of the oncoming nurse (LPN1) verifying that the medication count was correct. During audit of the controlled drug count, five blister cards containing controlled substances revealed punched, ripped, torn, or taped foil on the back of the card that secured the pill in the blister. The following was observed:- Chlordiazepoxide (benzodiazepine used to treat acute alcohol withdrawal, severe anxiety) 25 milligram (mg) capsules blister #13, #18, and #20 were ripped, torn, or punched open.- Oxycodone IR (immediate release) 5 mg tablets blister #14 was ripped, torn, or punched open.- Tramadol 50 mg tablets blister #14 was punched open and secured with a piece of transparent tape.- Lorazepam 0.5 mg tablets blister #7 was punched open and secured with a piece of transparent tape and blister #4 was ripped, torn, or punched open.- Tramadol 50 mg tablets blister #8 and #18 was ripped, torn, or punched open.During an interview on 02/15/26 at 10:45 AM, LPN1 said that she was required to sign the inventory count sheet with the off-going nurse after the narcotics were counted to verify that the count was done and the count was correct. LPN1 said that the exposed pills could be less effective, could fall out, or someone could take the pills for personal use. LPN1 said the procedure would be to ask another nurse to witness the destruction of the pill and sign that the pill was wasted.2. During an observation on 02/15/26 at 11:23 AM of Medication Cart #2 on [NAME] Unit with LPN2, it was revealed the shift change sheet of controlled substance inventory was missing the signature of the oncoming nurse (LPN2) verifying that the medication count was correct. During audit of the controlled drug count, three blister cards containing controlled substances revealed punched, ripped, torn, or taped foil on the back of the card that secured the pill in the blister. The following was observed:- Hydrocodone/APAP (acetaminophen) 5/325 mg tablets, blister #27 was punched open and secured with a piece of transparent tape.- Tramadol 50 mg tablets, blister #18 was punched open.- Tramadol 50 mg tablets, blister #1 was ripped, torn, or punched open.During an interview on 02/15/26 at 11:30 AM, LPN2 said that she forgot to sign the narcotic inventory sheet when she finished counting with the off-going nurse. LPN2 said there was a potential for loss or theft of controlled medications when the package was not secured. LPN2 said that she would notify the Director of Nursing (DON) of the unsecured medications.3. During an observation on 02/15/26 at 1:03 PM of Medication Cart #1 on Stone Unit with Registered Nurse (RN)3, it was revealed the shift change sheet of controlled substance inventory was missing the signature of the oncoming nurse (LPN3) verifying that the medication count was correct. During audit of the controlled drug count, two blister cards containing controlled substances revealed punched, ripped, torn, or taped foil on the back of the card that secured the pill in the blister. The following was observed:- Tramadol 50 mg tablets, blister #28 was punched open and secured with a piece of transparent tape.- Tramadol 50 mg tablets, blister #5 was ripped, torn, or punched open.During an interview on 02/15/26 at 1:07 PM, LPN3 said that she was supposed to sign the narcotic inventory sheet when she finished counting with the off-going nurse. LPN3 said that she did not check the back of the cards when she counted to hold the off-going nurse responsible for any discrepancies. LPN3 said that the blister cards appeared to be tampered with when there was any break in the seal.4. During an observation on 02/15/26 at 1:13 PM of Medication Cart #2 on Stone Unit with RN2, it was revealed three blister cards containing controlled substances with punched, ripped, torn, or taped foil on the back of the card that secured the pill in the blister. The following was observed:- Lorazepam 0.5 mg tablets, blister #12 was ripped, torn, or punched open.- Oxycodone/APAP 5/325 mg tablets, blister #7 was ripped, torn, or punched open.- Oxycodone/APAP 5/325 mg tablets, blister #8 was ripped, torn, or punched open.During an interview on 02/15/26 at 1:20 PM, RN2 said that it did not look like the back of the blister was punched all the way through. RN2 said that it was a risk of drug diversion whenever a seal was broken. RN2 said that she would notify the DON right away.During an interview on 02/15/26 at 1:45 PM, the DON said that the nurses and Unit Manager were responsible for overseeing procedures that prevented drug diversion such as monitoring the inventory log sheets and actual narcotic count.

Based on record review, interviews, and review of the Resident Assessment Instrument (RAI) Manual 3.0, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted within the required timeframes specified for one of 23 sampled residents (Resident (R) 68) reviewed for MDS. This failure had the potential for inaccurate or incomplete care planning and/or provision to the residents, and/or a lack of appropriate payment for services to the facility.Findings include:Review of the RAI Manual 3.0, dated 10/2019, revealed . OBRA [Omnibus Budget Reconciliation Act] required comprehensive assessments include the completion of both the MDS and CAA process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident's status has occurred or a significant correction to a prior comprehensive assessment is required . The MDS completion date (item Z0500B) must be no later than 14 days from the ARD [Assessment Reference Date] . and no later than 14 days after the determination that the criteria for an SCSA [Significant Change in Status Assessment] were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than .Review of R68's undated Face Sheet from the electronic medical record (EMR) Resident tab revealed a facility admission date of 04/24/23 with medical diagnoses that included type II diabetes mellitus, chronic kidney disease, and altered mental status.Review of R68's annual MDS with an Assessment Reference Date (ARD) of 01/10/26, located in the EMR under the RAI tab and the MDS 3.0 Assessments tab, revealed it was signed by the Minimum Data Set Coordinator (MDSC)2 as completed on 01/16/26. However, the status of this assessment was noted as Production Rejected. Further review of R68's MDS assessments revealed the resident's quarterly MDS assessment, with an ARD of 10/10/25, was R68's most recent assessment that had been successfully transmitted to the Centers for Medicare and Medicaid Services (CMS).During an interview on 02/17/26 at 10:10 AM, MDSC1 and MDSC2 reviewed R68's annual MDS, with an ARD date of 01/10/26, and confirmed the assessment's status was Production Rejected and had not been transmitted to CMS. MDSC2 confirmed that she signed the resident's annual MDS as complete on 01/16/26 but did not know why it was noted as rejected and was not transmitted to CMS.During an interview on 02/17/26 at 10:45 AM, MDSC1 stated she rejected R68's annual MDS, with an ARD of 01/10/26, and failed to transmit this assessment to CMS. MDSC1 stated she could not recall why she rejected this assessment but would transmit this MDS to CMS on 02/17/26. During an interview on 02/17/26 at 5:05 PM, the Administrator stated she expected MDS assessments to be transmitted to CMS on time. The Administrator stated the facility did not have MDS policies but used the RAI Manual for their MDS procedures.

Based on observation, record review, interview, and policy review, the facility failed to ensure nursing staff were competent in gastric tube (GT) management, including verifying tube placement prior to flushing and performing GT replacement, for one of three residents (Resident (R) 6) reviewed for tube feeding management out of a total sample of 23. The facility failed to ensure staff competency was validated through return demonstration of GT-related skills, use of a competency checklist, and evaluation of staff performance following training prior to providing direct resident care. This failure placed R6 at risk for aspiration, respiratory distress, and injury if fluids were administered into a GT that was not correctly positioned or if the tube was improperly replaced at the bedside.Findings include:Review of the facility policy titled, Staff Development for Nursing Employees, revised 01/01/24, revealed Policy: 1. Staff development and learning through ongoing education including in-servicing, training, and other activities that improve staff's competence will be offered according to Facility Policies and Procedures . 2. The nursing staff will receive initial job training and an assessment of their ability to perform specific job duties as well as an understanding of the Facility . Purpose: To ensure that all nursing staff possess the appropriate competencies and skills sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each residents' rights, physical, mental, and psychosocial well-being.Review of the facility policy titled, Gastrostomy Tue Replacement (Balloon Type), revised May 5, 2023, revealed Policy: The qualified nursing staff will replace balloon type gastrostomy tube as guided by: State specific nurse practice acts . 15. Feeding/Medication administration is held until placement has been verified and documented by the physician, his/her designee (Nurse Practitioner, Enterostomal Therapist experienced in Gastrostomy Tube replacement, or qualified licensed nurse) as determined by attending physician. The feeding is held for a clinically appropriate time as determined by the attending physician in order to prevent dehydration/loss of nutrition. 16. Document.Review of R6's Resident Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R6 was admitted to the facility on [DATE], the latest return to facility was 11/29/23. R6 had diagnoses that included dysphagia following cerebral infarction (trouble swallowing after stroke), gastroesophageal reflux disease ([GERD] chronic acid reflux) without esophagitis (inflammation, irritation, or swelling of the esophagus lining), and gastrostomy (G-tube) status. R6 received hospice services as of 11/21/25.Review of R6's Orders, located under the Resident tab of the EMR, reflected the following orders:Order date: 11/18/22 - Enteral Feeding: Placement Verification - Check Residual Special Instructions: If residual 150 ml [milliliters] or less reinsert volume into stomach and continue feeding. If greater than 150 ml, hold feeding and notify physician.Order date: 10/12/23 - Enteral Feeding: Flush tube with 30 cc's [cubic centimeters] warm water before and after medication administration Every ShiftOrder date: 08/13/25 - Eternal Tube: 16 Fr [French] g-tube with 5cc balloon may change for displacement, damage, occlusion As NeededOrder date: 01/27/25 - 30 mL of water before and after medication administration via gtube Every ShiftOrder date: 02/15/26 - Enteral Feeding: May change NG/G (nasogastric/gastric) Tube for displacement/damage/occlusion As NeededReview of R6's Care Plan, dated 02/18/22 and located under the RAI (Resident Assessment Instrument) tab of the EMR, reflected a category for Category: Feeding Tube [R6] requires tube feeding R/T [related to] history of oral cancer. Interventions included Check placement and patency of feeding tube before each feeding or medication administration. During an observation on 02/15/26 at 9:51 AM, Licensed Practical Nurse (LPN)1 disconnected the formula tubing from R6's GT feeding port. LPN1 did not verify GT placement by checking gastric residual as ordered prior to attempting to flush the tube. LPN1 poured approximately 30 cc of water into a syringe connected to the feeding port; however, the water did not infuse, indicating the GT was not patent. LPN1 then poured the water from the syringe into a cup, detached the syringe, replaced the cap on the feeding port, and left the room.During an interview on 02/15/26 at 10:08 AM, prior to re-entering R6's room, LPN1 stated she had spoken with the Director of Nursing (DON), who instructed her to use the syringe plunger to push the water through the GT. LPN1 stated that she would verify tube placement by pushing air into the GT with a syringe while listening to the stomach with a stethoscope near the insertion site, explaining this was the method she learned in school. LPN1 acknowledged that pushing water through the GT without verifying placement could place R6 at risk for aspiration. LPN1 then left to retrieve a stethoscope.During observation and interview on 02/15/26 at 12:34 PM, LPN1 attached a 60-cc syringe to R6's GT feeding port and withdrew gastric contents to check residual, then returned the residual. LPN1 removed the plunger from the syringe, reattached the syringe to the feeding port, poured approximately 30 cc of water into the syringe, and the water infused by gravity through the GT without difficulty. LPN1 stated the water flowed without a problem because the DON had replaced the gastric tube. When asked to clarify, LPN1 confirmed the DON had removed the previous gastric tube and inserted a new gastric tube. LPN1 said that she was not sure if it was scheduled to replace the GT and confirmed that no other interventions were tried to unclog the GT before replacing it.During an interview on 02/15/26 at 2:07 PM, the DON verified that he replaced R6's GT and was going to document as soon as possible. The DON said that R6 had an order to replace the GT as needed. The DON said that he received training, was checked off for competence, and replacing the GT was within his scope of practice. The DON said that it was the facility protocol to replace a resident's GT at the bedside if it would avoid sending a resident to the hospital unnecessarily.Review of R6's Treatment Administration Report (TAR), located under the Resident tab of the EMR, reflected LPN1's initials on 02/15/26 at 2:12 PM, next to the order for Eternal Tube: 16 Fr g-tube with 5cc balloon may change for displacement damage occlusion. In the comment section, LPN1 wrote blockage for the reason the GT was replaced.Review of R6's Progress Notes, located under the Resident tab of the EMR, dated 02/15/26 at 6:10 PM, and written by LPN1, revealed, G tube was blocked and not flushing. PRN [as needed] order administered by DON, resident tolerated well. G tube change effective and flushing well. No distress noted.During an interview on 02/16/26 at 12:17 PM, the Assistant Director of Nursing (ADON) stated she served as the nurse educator and was responsible for ensuring nursing staff competency skills checkoffs were completed during new-hire orientation, annually, and as needed. The ADON stated nurses were not permitted to perform skilled care without demonstrating competency. The ADON stated training and competency documentation were maintained in personnel files by the Human Resources (HR) department.Review of LPN1's personnel file, provided by the Administrator, revealed a date of hire of 10/28/25. Documentation showed LPN1 completed competency validation on 10/28/25 for Isolation - Standard and Transmission-Based Precautions, Handwashing, and Perineal Care, evaluated by Registered Nurse (RN) 1. The personnel file did not include training transcripts, graded tests, or competency validation for GT management or GT replacement.Review of the DON's personnel file, provided by the Administrator, revealed a promotion from LPN to RN DON on 05/10/24. The DON's file included competency documentation for multiple nursing skills; however, there was no documentation of training or competency validation for gastric tube management or replacement. The DON's competencies had been evaluated by the ADON.Review of the ADON's personnel file, provided by the Administrator, revealed a promotion from LPN to ADON on 03/15/23. The ADON's file did not include documentation of training or competency validation for gastric tube management or replacement.

Based on record review, interviews, and facility policy review, the facility failed to provide the reason for transfer or discharge, to the resident and/or the resident representative upon discharge to the hospital, in writing for 2 of 2 residents (Resident (R)58 and R70) reviewed for transfer and discharge. This failure had the potential to affect residents' understanding for the reason of transfer. Findings include: Review of the facility's policy titled, SOCIAL SERVICES POLICIES AND PROCEDURES: DISCHARGE NOTIFICATION, revised on 06/09/23, documented, Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. 1. Review of R58's Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated that he was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure, hypertension, and chronic obstructive pulmonary disease. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/24, and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R58 was cognitively intact. Further review of the MDS revealed R58 needed supervision and/or touch assistance with all Activities of Daily Living (ADL). Review of R58's Hospital Summary, dated 01/07/25, located in the Resident Records tab of the EMR, revealed an admitted [DATE], and a discharge date of [DATE], with the reason for admission being viral gastroenteritis and acute kidney injury on chronic kidney disease. 2. Review of R70's Face Sheet located under the Profile tab in the EMR indicated that his current admission to the facility was on 11/26/24, with diagnoses including but not limited to: diabetes mellitus type two with hyperglycemia, hypertension, and coronary artery disease. Review of R70's admission MDS with an ARD of 01/26/24, and located in the MDS tab of the EMR revealed a BIMS score of 8 out of 15, indicating R70 was moderately cognitively impaired. Further review of the MDS revealed R70 needed supervision and/or touch assistance with all ADL. Review of R70's Hospital Summary located in the Resident Records tab of the EMR, revealed an admitted to the hospital of 02/07/24, and a discharge date of [DATE], with the reason for admission being episode of syncope. Review of R58's and R70's EMR revealed no documentation of the reason for discharge provided in writing. During an interview on 01/09/25 at 10:39 AM, the Social Services Director (SSD) stated that she did not understand about sending a reason for transfer or discharge in writing to the resident, resident representative, and the ombudsman because the facility sent a bed hold that was completed by the nurses at time of discharge to the hospital. The SSD also stated that the bed hold was all they had. During an interview on 01/09/25 at 10:53 AM, the Director of Nurses (DON) stated the nurses had a check list that they filled out when a resident transferred to the hospital. The DON provided a copy of the check list and stated it was everything they did when a resident went out. During an interview on 01/09/25 at 3:00 PM, the Administrator stated that he was not aware the facility was not completing a written discharge/transfer notice.

Based on record review, interviews, and facility policy review, the facility failed to provide the complete Bed Hold to the resident and or the resident representative upon discharge to the hospital for 2 of 2 residents (Resident (R) 58) and R70) reviewed for transfer and discharge. This failure had the potential to affect the resident's knowledge on return to the facility. Findings include: Review of the facility's policy titled, FACILITY'S POLICY AND STATE REQUIREMENTS FOR TEMPORARY LEAVE] BED-HOLD, revised on 06/09, documented, In order to ensure the resident's specific bed is available to him/her when he/she is ready to return, the resident or his/her representative shall pay the basic per diem rate of $__ for each day during the bed-hold period. 1. Review of R58's Face Sheet located under the Profile tab in the electronic medical record (EMR) indicated that he was admitted to the facility on [DATE], with diagnoses including but not limited to: acute respiratory failure, hypertension, and chronic obstructive pulmonary disease. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/13/24, and located in the MDS tab of the EMR, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R58 was cognitively intact. Further review of the MDS revealed R58 needed supervision and/or touch assistance with all Activities of Daily Living (ADL). Review of R58's Hospital Summary, dated 01/07/25, located in the Resident Records tab of the EMR, revealed an admitted [DATE], and a discharge date of [DATE], with the reason for admission being viral gastroenteritis and acute kidney injury on chronic kidney disease. 2. Review of R70's Face Sheet located under the Profile tab in the EMR indicated that his current admission to the facility was on 11/26/24, with diagnoses including but not limited to: diabetes mellitus type two with hyperglycemia, hypertension, and coronary artery disease. Review of R70's admission MDS with an ARD of 01/26/24 and located in the MDS tab of the EMR, revealed a BIMS score of 8 out of 15 which indicated R70 was moderately cognitively impaired. Further review of the MDS revealed R70 needed supervision and/or touch assistance with all ADL. Review of R70's Hospital Summary located in the Resident Records tab of the EMR, revealed an admitted to the hospital of 02/07/24, and a discharge date of [DATE], with the reason for admission being episode of syncope. Review of R58's and R70's EMR revealed no copy of the Bed Hold was located. During an interview on 01/09/25 at 10:39 AM, the Social Services Director (SSD) stated that she sent the ombudsman a list of transfers and discharges every month. She stated the Business Office Manager (BOM) sent the notification to the family and residents for bed holds. The SSD also stated the nurse notified the family if a resident was sent out. She stated there was a packet at the nurse's station that the nurse filled out; made a copy for the BOM to send to the resident representative and the original was sent with the ambulance for the resident. The SSD concluded, As far as I know that is all we have. During an interview on 01/09/25 at 10:53 AM, the Director of Nurses (DON) stated the nurses had a check list that they filled out when a resident transferred to the hospital. The DON provided a copy of the check list and stated that was everything they did when a resident went out. During an interview on 01/09/25 at 11:45 AM, the BOM stated that she sent the resident representative a copy of the bed hold, and the nurse sent the original with the resident at time of transfer. The BOM stated that R70 did not have a resident representative so there was not one sent. The BOM also stated that the Bed Hold for R58 was not completed because it was missing the daily rate for the room charge. During an interview on 01/09/25 at 3:00 PM, the Administrator stated that the Bed Hold notice for R70 was probably not sent to the resident representative and that the Bed Hold for R58 was incomplete due to the fact that it did not have the daily per diem rate to hold the room.

Based on review of facility policy, interview, and record review, the facility failed to provide appropriate supervision for Resident (R)1, resulting in R1 successfully eloping from the facility, for 1 of 3 residents reviewed. On 09/18/24 at 3:35 PM, the Administrator was notified that the failure to ensure a resident receives appropriate supervision, to prevent an elopement, constituted Immediate Jeopardy at F689. On 09/18/24 at 3:35 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of 09/15/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 09/18/24, the facility provided an acceptable IJ Removal Plan. On 09/18/24 the survey team, validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 09/16/24. An extended survey was conducted in conjunction with the Complaint Survey for non-compliance at F689, constituting substandard quality of care. Findings include: Review of the facility policy titled Elopement Risk Assessment with a revision date of 11/01/17, documented under procedure, 3. Interventions will be added to the patient's/resident's care plan after analyzing the information obtained. 4. completes an elopement risk assessment and presents the information to the Interdisciplinary Team for further interventions. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: Huntington's disease, major depressive disorder, restlessness and agitation, and insomnia. Review of R1's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/24, revealed that a Brief Interview for Mental Status (BIMS) was not conducted because the resident is rarely/never understood. Further review of the MDS revealed R1 was severely impaired regarding Cognitive Skills for Daily Decision Making. Additionally, R1's assessment for Rejection of Care and Wandering indicated that these behaviors did not occur. Review of R1's Care Plan with a start date of 07/15/24, documented, [R1] appears to have recall deficit as evidenced by: inability to understand commands/communication, poor decision making, related to diagnosis of: Huntington's Disease. Further review of the Care Plan did not reveal a Care Plan related to wandering/elopement, prior to the incident. Review of R1's Elopement Risk Observation dated 07/17/24, revealed R1 is confused and has a history of wandering. Further review revealed there was no scoring criteria related to the risk and no interventions listed. Review of R1's Progress Note revealed a note dated 09/15/24 at 3:44 AM, which documented, Door alarm at nurses station was alarming. Upon arrival it was noted that resident was not in his room. Resident was outside in company van. Staff assisted resident back into wheelchair. Resident was combative. Staff assisted resident back into room. 15 checks initiated on resident. During an interview on 09/18/24 at 1:08 PM, Registered Nurse (RN)1 revealed, sometimes R1 does try to go out the side door on Stone, maybe about 1 or 2 months ago. The Interdisciplinary Team was notified and reviews the assessment. Resident did not have a wander guard on prior to the incident. The Interdisciplinary Team makes the decision to implement interventions. During an interview on 09/18/24 at 1:55 PM, Licensed Practical Nurse (LPN)1 revealed, R1 is combative and has exit seeking behavior. R1 is difficult to redirect. R1 has always had a behavior of exit seeking. Supervisors are notified in 24-hour report and progress notes. R1 did not have a wander guard on the day of incident. During an interview on 09/18/24 at 2:20 PM, the Director of Nursing (DON) stated, R1 got out and was found in the van. The DON questioned the resident being found in the van, due to the resident's physical condition and there was nothing moved around in the van. The DON verified the driver side door of the van was unlocked, but the passenger side doors were locked. The DON further stated, I did not know that he was wandering/exit seeking. He had a wanderguard in place prior to this incident but it was taken off because he went a long time without the behaviors. The DON concluded, video footage was reviewed, and nothing was found. During an interview on 09/18/24 at 2:47 PM, the Administrator revealed, the cameras haven't been working for a while. The resident did get out but was found immediately. The Administrator stated, I was told there was a nine minute window that the resident wasn't accounted for. I don't know off the top of my head the criteria that a wandergaurd would need to be placed on a resident based on the elopement assessment. I will have to get back to you on that. I was not aware that the resident was having exit seeking behaviors leading up to the incident. On 09/18/24, the facility provided an acceptable IJ Removal Plan, which included the following: Resident #1 without injury and elopement risk evaluation repeated on 9/15/24 with interventions in place per care plan. Director of Nursing and Administrator will be reeducated on the Elopement Policy and Process on 9/18/24 by the Clinical Consultant including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors. Elopement risk Assessments will be reviewed for completion and accuracy on 9/18/24 by the Director of Nursing/Designee on current residents in facility to identify residents at risk for elopement. Those residents identified at risk will have interventions initiated and care plan updated on 9/18/24. Licensed Nurses will be reeducated on the Elopement Policy and Process on 9/18/24 by the Director of Nursing/Designee including: Completing the elopement risk evaluation thoroughly and implementing interventions based on risk identified. Documentation of exit seeking behavior and completing elopement risk evaluation for increased exit seeking behaviors. Licensed Nurses not receiving this education by 9/18/24 will receive prior to their next scheduled shift. Facility Activity Report and 24hour report will be reviewed Monday - Friday in clinical morning meeting to validate elopement assessments completed. The Director of Nursing/Designee will review completed elopement assessments Monday - Friday in clinical morning meeting to validate accuracy and interventions have been implemented accordingly. Ad hoc QAPI held on 9/18/24. Medical Director was notified of the Immediate Jeopardy and the contents of this plan on 9/18/24.

Based on interview and record review, the facility failed to provide services to Resident (R)1 necessary to R1 to avoid physical harm, pain, mental anguish, or emotional distress for 1 of 9 residents reviewed. R1 exited the facility on 06/22/2023 at approximately 7:55 AM and was found at 8 AM. Certified Occupational Therapy Assistant (COTA)1 found the resident in the receptionist's car. This was confirmed by the receptionist, administrator, housekeeping staff #1 and #2, Certified Nursing Aide (CNA)1, and the Assistant Director of Nursing. The resident was known to be an elopement risk, but no interventions were put in place to protect the resident from elopement. Because the facility failed to implement interventions recommended to protect R1 from wandering / elopement, the resident was able to elope from the facility without permission or supervision. This placed her at increased risk of a serious adverse outcome, such as severe harm or death. On 06/26/2023 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/22/2023 at 8 AM, R1 was discovered outside the facility, in the driver's seat of the receptionist's vehicle. The facility's failure to implement wandering / elopement interventions when the resident was identified as an elopement risk on 05/02/2023 constituted immediate jeopardy at F600. The facility presented an acceptable plan of removal of the immediate jeopardy on 06/27/2023 at 10:50 AM. The survey team validated that the immediate jeopardy was removed on 06/27/2023 at 12:30 PM following the facility's implementation of the plan of removal of the immediate jeopardy. The facility remained out of compliance at F600 at a lower scope and severity of D (isolated with potential for more than minimal harm) following removal of the IJ. The findings include: Review of undated facility policy titled Abuse, Neglect, Exploitation, or Mistreatment revealed that Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, abnormalities of gait and mobility, restlessness and agitation, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/07/2023 revealed the resident scored a 99/15 in her Brief Interview for Mental Status, indicating she was unable to complete the interview. Review of COTA1's statement written to the facility on [DATE] revealed pulled into the parking lot and identified R1 sitting within her wheelchair by a parked vehicle. Upon approaching, she then realized the wheelchair was empty, and the resident was in the front seat of the vehicle. She alerted the receptionist (the car's owner), and then the Administrator. Interview with COTA1 on 06/26/2023 at 2:15 PM confirmed her statement to the facility. She identified the resident based on the pink shirt on her wheelchair, then realized the resident was inside the vehicle. She alerted the receptionist and then the administrator. The resident had demonstrated prior wandering behaviors to COTA1, such as rolling into therapy when the door was open. Review of housekeeping staff #1's statement to the facility written on 06/22/2023 revealed she saw the resident sitting in an employee's car when she pulled up to the facility at start of shift (approximately 8 AM). Staff were already outside trying to get the resident back in. Interview with housekeeping staff #1 on 06/26/2023 at approximately 2 PM confirmed her statement to the facility. She spotted the wheelchair beside the receptionist's car. She asked the Administrator what was happening, and one of the other staff members said they were trying to get R1 to leave the vehicle. Review of housekeeping staff #2's statement to the facility written on 06/22/2023 revealed she walked outside with another employee to assist the resident out of the car. Interview with housekeeping staff #2 on 06/26/2023 at 2:44 PM confirmed her statement to the facility. She heard the resident was in the employee's car and went out to help take her back inside. The resident was uninjured. Review of the Assistant Director of Nursing (ADON) statement to the facility on [DATE] revealed she was asked to help the resident back to the facility, but by that point the resident was already being returned to the facility with staff assistance. She did notice the resident wandering earlier that morning. Interview with the ADON on 06/26/2023 at approximately 2:20 PM confirmed her statement to the facility. Interview also revealed she had noted R1 to wander often in the facility. She would go up and sit by the door, though she had never tried to leave. She had, however, expressed a desire to leave the facility. The resident is always looking for her daughter, her car, or saying she needs to get to work. Review of the receptionist's statement to the facility written on 06/22/2023 revealed she clocked in that morning at 8 AM. She walked back to the front office, when therapy staff told her a resident was in her car. She went to check, then told therapy to get the administrator. She waited with the resident while the administrator and staff came to assist the resident. Interview with the receptionist on 06/26/2023 at approximately 1:48 PM confirmed her statement to the facility. She came into the facility that morning just before 8 AM and went to clock in. When she returned to the front, COTA1 told her R1 was in her car. There were no keys in the car, so the resident could not have driven or turned it on. Review of R1's chart revealed an Elopement Risk Assessment recorded on date 05/02/2023 at 11:07 AM. The assessment revealed R1 was not oriented to person, place, or time; the resident was confused; the resident did not have safe decision-making capabilities; the resident had a history of wandering; the resident had attempted to leave the health care center; the resident was not easily redirected; the resident ambulatory; and the resident has a diagnosis that requires supervision. The recommended intervention was a wander guard to be placed on the ankle and function to be monitored every shift. Interview with the administrator on 06/26/2023 at approximately 1:50 PM revealed she saw R1 that morning just before 8 AM. She was heading to the front of the facility, which is not unusual for the resident - who often sits by the receptionist. Someone called for her to come to the parking lot, and she saw R1 in the driver's seat of the receptionist's vehicle. The receptionist parked beside her, about 50 feet from the main entrance. The resident would have to cross the parking lot to the street side to reach where the vehicles were parked. R1 had a wandering assessment on 05/02/2023 that determined the resident to be capable of ambulation, expressing the desire to leave the facility, and requiring of supervision. The primary intervention to protect wandering / eloping residents is a wander guard, though R1 did not have one ordered at the time of the incident. It has since been added to her orders and care plan. This was confirmed by chart review. The administrator confirmed that the resident does often wander and has gone into other resident's rooms. She did not know why a wander guard was not already in place to protect the resident. Review of R1's Care Plan revealed the care area and interventions for the resident's elopement risk has a start date of 06/22/2023 - the date of the elopement - despite the resident demonstrating wandering and exit seeking behaviors prior to that date. Follow-up interview with the administrator on 06/26/2023 at 4:20 PM revealed that at the time of the elopement, facility policy was to lock the front door when the receptionist was not on duty. When the receptionist entered that morning for her shift, she unlocked the door, and when she left the front area to clock in, the resident was able to elope from the facility. Review of timeanddate.com revealed the temperature and weather in St. [NAME] on the morning of 06/22/2023 was 67 degrees Fahrenheit and sunny. Multiple observations and interview attempt on 06/26/2023 revealed no concerns relating to neglect at time of survey. The resident was unharmed on multiple observations, and there was no observable psychological distress related to the elopement. The resident was not interviewable. The facility's removal plan included the following: Staff escorted R1 back into the facility on [DATE] at 8 AM. Staff performed a complete body audit on R1 on 06/22/2023 at 8:30 AM. A wander guard was placed on R1 on 06/22/2023, and an order was updated to reflect the new placement. On 06/22/2023 at 8:30 AM, facility audited all remaining residents in the facility, and all residents were accounted for. On 06/22/2023 at 8:50 AM, Maintenance validated exit doors were secure. On 06/22/2023 at 1 PM, residents at risk for elopement had an elopement evaluation repeated. Facility initiated re-education of staff on monitoring wander guard for placement and function for those who are an elopement risk on 06/22/2023. Staff will be re-educated prior to their next shift. On 06/22/2023, R1's care plan was reviewed for accuracy and updated as appropriate. On 06/22/2023, the front door was locked with a code required for entry and exit at all times - including business hours. Previously, the door had been unlocked when the receptionist was on-duty. Facility staff received re-education on abuse, neglect, and misappropriation on 06/26/2023. All staff will be re-educated prior to their next shift. The DON will randomly audit a minimum of 5 residents' elopement assessments and care plans weekly x 4, monthly x 2, to validate accuracy and placement of interventions implemented. The maintenance director will inspect facility doors thrice weekly x 4 weeks, then weekly x 2 additional months to validate doors are functioning properly. An ad hoc QAPI meeting was held on 06/22/2023 regarding the elopement.

Based on interview and record review, the facility failed to provide supervision necessary to prevent elopement for 1 of 9 residents reviewed. R1 eloped from the facility on 06/22/2023 at approximately 7:55 AM and was found at 8 AM. Certified Occupational Therapy Assistant (COTA)1 found the resident in the receptionist's car. This was confirmed by the receptionist, administrator, housekeeping staff #1 and #2, Certified Nursing Aide (CNA)1, and the Assistant Director of Nursing. The resident was known to be an elopement risk, but no interventions were put in place to protect the resident from elopement. Because the facility failed to provide supervision to R1 to prevent elopement, the resident was placed her increased risk of a serious adverse outcome, such as severe harm or death. On 06/26/2023 at approximately 3 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations has caused or was likely to cause serious injury, serious harm, serious impairment, or death. On 06/22/2023 at 8 AM, R1 was discovered outside the facility, in the driver's seat of the receptionist's vehicle. The elopement constituted immediate jeopardy at F689. The facility presented an acceptable plan of removal of the immediate jeopardy on 06/27/2023 at 10:50 AM. The survey team validated that the immediate jeopardy was removed prior to the start date of the survey, on 06/23/2023. Verification shown F689 was identified as IJ Pastnoncompliance for 06/22/2023-06/23/2023. The findings include: Review of facility policy titled Leadership Policies and Procedures about Elopement and last revised on 11/01/2017 revealed the policy aim is To safely and timely redirect patients / residents to a safe environment. Interview with the Administrator on 06/26/2023 at 3:29 PM revealed the facility defined elopement as a situation in which the resident was unsupervised and outside the building. R1 was admitted to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, abnormalities of gait and mobility, restlessness and agitation, and muscle weakness. Review of the resident's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/07/2023 revealed the resident scored a 99/15 in her Brief Interview for Mental Status, indicating she was unable to complete the interview. Review of a 06/15/2023 progress note for R1 written on 06/15/2023 at 10:26 AM revealed the night staff reported that the resident kept trying to return to her old room and required social services to redirect her multiple times during the night. Review of a 06/20/2023 progress note or R1 written at 2:28 AM revealed that the resident was frequently wandering in and out of other's rooms. Review of COTA1's statement written to the facility on [DATE] revealed pulled into the parking lot and identified R1 sitting within her wheelchair by a parked vehicle. Upon approaching, she then realized the wheelchair was empty, and the resident was in the front seat of the vehicle. She alerted the receptionist (the car's owner), and then the Administrator. Interview with COTA1 on 06/26/2023 at 2:15 PM confirmed her statement to the facility. She identified the resident based on the pink shirt on her wheelchair, then realized the resident was inside the vehicle. She alerted the receptionist and then the administrator. The resident had demonstrated prior wandering behaviors to COTA1, such as rolling into therapy when the door was open. Review of housekeeping staff #1's statement to the facility written on 06/22/2023 revealed she saw the resident sitting in an employee's car when she pulled up to the facility at start of shift (approximately 8 AM). Staff were already outside trying to get the resident back in. Interview with housekeeping staff #1 on 06/26/2023 at approximately 2 PM confirmed her statement to the facility. She spotted the wheelchair beside the receptionist's car. She asked the Administrator what was happening, and one of the other staff members said they were trying to get R1 to leave the vehicle. Review of housekeeping staff #2's statement to the facility written on 06/22/2023 revealed she walked outside with another employee to assist the resident out of the car. Interview with housekeeping staff #2 on 06/26/2023 at 2:44 PM confirmed her statement to the facility. She heard the resident was in the employee's car and went out to help take her back inside. The resident was uninjured. Review of the Assistant Director of Nursing (ADON) statement to the facility on [DATE] revealed she was asked to help the resident back to the facility, but by that point the resident was already being returned to the facility with staff assistance. She did notice the resident wandering earlier that morning. Interview with the ADON on 06/26/2023 at approximately 2:20 PM confirmed her statement to the facility. Interview also revealed she had noted R1 to wander often in the facility. She would go up and sit by the door, though she had never tried to leave. She had, however, expressed a desire to leave the facility. The resident is always looking for her daughter, her car, or she say, needs to get to work. Review of the receptionist's statement to the facility written on 06/22/2023 revealed she clocked in that morning at 8 AM. She walked back to the front office, when therapy staff told her a resident was in her car. She went to check, then told therapy to get the administrator. She waited with the resident while the administrator and staff came to assist the resident. Interview with the receptionist on 06/26/2023 at approximately 1:48 PM confirmed her statement to the facility. She came into the facility that morning just before 8 AM and went to clock in. When she returned to the front, COTA1 told her R1 was in her car. There were no keys in the car, so the resident could not have driven or turned it on. Interview with the administrator on 06/26/2023 at approximately 1:50 PM revealed she saw R1 that morning just before 8 AM. She was heading to the front of the facility, which is not unusual for the resident - who often sits by the receptionist. Someone called for her to come to the parking lot, and she saw R1 in the driver's seat of the receptionist's vehicle. The receptionist parked beside her, about 50 feet from the main entrance. The resident would have to cross the parking lot to the street side to reach where the vehicles were parked. R1 had a wandering assessment on 05/02/2023 that determined the resident to be capable of ambulation, expressing the desire to leave the facility, and requiring of supervision. The primary intervention to protect wandering / eloping residents is a wander guard, though R1 did not have one ordered at the time of the incident. It has since been added to her orders and care plan. The administrator confirmed that the resident does often wander and has gone into other resident's rooms. She did not know why a wander guard was not already in place to protect the resident. Follow-up interview with the administrator on 06/26/2023 at 4:20 PM revealed that at the time of the elopement, facility policy was to lock the front door when the receptionist was not on duty. When the receptionist entered that morning for her shift, she unlocked the door, and when she left the front area to clock in, the resident was able to elope from the facility. Review of timeanddate.com revealed the temperature and weather in St. [NAME] on the morning of 06/22/2023 was 67 degrees Fahrenheit and sunny. Multiple observations and interview attempt on 06/26/2023 revealed no concerns relating to neglect at time of survey. The resident was unharmed on multiple observations, and there was no observable psychological distress related to the elopement. The resident was not interviewable. The facility's removal plan included the following: Staff escorted R1 back into the facility on [DATE] at 8 AM. Staff performed a complete body audit on R1 on 06/22/2023 at 8:30 AM. A wander guard was placed on R1 on 06/22/2023, and an order was updated to reflect the new placement. On 06/22/2023 at 8:30 AM, facility audited all remaining residents in the facility, and all residents were accounted for. On 06/22/2023 at 8:50 AM, Maintenance validated exit doors were secure. On 06/22/2023 at 1 PM, residents at risk for elopement had an elopement evaluation repeated. Facility initiated re-education of staff on monitoring wander guard for placement and function for those who are an elopement risk on 06/22/2023. Staff will be re-educated prior to their next shift. On 06/22/2023, R1's care plan was reviewed for accuracy and updated as appropriate. On 06/22/2023, the front door was locked with a code required for entry and exit at all times - including business hours. Previously, the door had been unlocked when the receptionist was on-duty. Facility staff received re-education on abuse, neglect, and misappropriation on 06/26/2023. All staff will be re-educated prior to their next shift. The DON will randomly audit a minimum of 5 residents' elopement assessments and care plans weekly x 4, monthly x 2, to validate accuracy and placement of interventions implemented. The maintenance director will inspect facility doors thrice weekly x 4 weeks, then weekly x 2 additional months to validate doors are functioning properly. An ad hoc QAPI meeting was held on 06/22/2023 regarding the elopement.

Based on record review, interviews, and policy review, the facility failed to ensure Certified Nursing Assistant (CNA1) followed the resident positioning procedure during resident care for 1 of 2 residents (Resident (R) 16) reviewed for accidents out of a total sample of 21 residents. As a result of the deficient practice R16 fell and was harmed when she sustained bilateral leg fractures. Findings include: Review of the facility's undated policy titled, Hartman's Nursing Assistant Basics Fifth Edition revealed when positioning a resident .Gently slide your hands under the resident's head and shoulders and move them toward you. Gently slide your hands under her midsection and move it toward you. Gently slide your hands under the hips and legs and move them toward you . Review of R16's Face Sheet located in the Resident tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE]. R16's diagnoses included but was not limited to obesity. Review of R16's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/22 revealed R16 required total dependence in bathing with a one-person assist. This MDS further revealed R16 required extensive assistance in bed mobility with a one-person assist and a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated R16 was moderately cognitively impaired at the time of this assessment. Review of R16's BIMS in the MDS with an ARD of 01/11/23, located in the RAI tab of the EMR, revealed R16 scored a 14 out of 15 which indicated R16 was cognitively intact. During an initial screening interview on 02/06/23 at 11:30 AM, R16 stated I fell out of bed and broke my kneecaps. further stated it happened about two months ago while receiving morning care. During an interview on 02/08/23 at 10:51 AM, R16 stated The girl [CNA1] was cleaning me when I broke my legs. She asked me to roll over, and she pushed at the same time. I fell off the other side of the bed. Some nurses came in to help me get up. Review of the incident investigation report, dated 08/30/22, revealed R16 fell out of bed while receiving a bath by CNA1. The incident report further documented R16 had bilateral knee pain and x-rays were ordered. The report included a recommendation for side rails and an updated care plan to add a floor mat. The incident report included in service training dated 09/01/22 for staff regarding proper positioning of turning residents towards them during care. Review of mobile x-ray located in the Documents tab under Radiology revealed bilateral fractures of the distal femurs (the area of the thigh bone near the knee). Review of R16's records concerning her hospital stay from 08/31/22 to 09/06/22, located in Resident tab under Hospital records, revealed the resident underwent an open reduction and internal fixation surgery for the bilateral distal femur fractures. Open reduction and internal fixation surgery includes the use of screws, plates, sutures, or rods to hold the broken bone together. During an interview on 02/08/23 at 10:45 AM, CNA2 said Licensed Practical Nurse (LPN1) called to help pick R16 up off the floor. When I got in the room the bed was as high as it could go. She [CNA1] said she pulled the pad and she [R16] fell on the other side of the bed. I told her [CNA1] you must have pushed her too far; you could have asked her to roll over. CNA1 stated R16 was able to turn herself in bed. During an interview on 02/08/23 at 11:08 AM, LPN1 who worked the day shift starting at 7:00 AM on 08/30/22, said she was notified by staff around 9:00 AM that R16 was complaining of pain. LPN1 said The CNA came to get me; I went down there and pulled the covers back. The left knee was swollen. I reported it and obtained an order for X-rays. It had to have happened during rounds and it was not reported to me by the night shift agency nurse. During an interview on 02/08/23 at 11:18 AM, LPN2 said I worked the other hall. We were making our last rounds and I was called to the room, went in there and found resident was on the floor. The patient was angry. For that patient to fall she had to be too close to the edge of the bed and the bed was in a high position. I told them to leave the resident and go get her nurse, before we get her up off the floor, we need to ensure the patient is ok, so I went and got her [LPN1]. It was change of shift and I went back to complete my work. During an interview on 02/08/23 at 11:35 AM, the Director of Nursing (DON) said I was told that the resident had a fall on night shift and now was complaining of pain so we got an order for x-ray. The nurse said the CNA was bathing the resident and she rolled the resident away instead of towards her. The resident told me she fell out of the bed when she was getting cleaned up. I did not talk with the CNA, she was agency. We did in servicing that day. Then she [CNA1] put in her resignation effective immediately. The DON stated, The CNAs should roll the patient towards them to prevent falls during care.

Based on review of facility policy, record review, observations, and interviews, the facility failed to ensure that one (Resident (R) 2) of 21 sampled residents were treated in a respectful and dignified manner during dining. Specifically, staff stood over the resident while feeding the resident the meal, rather than sitting at the resident's eye level, maintaining face-to-face contact. Findings include: Review of facility policy titled, Nutrition - Assisting the Patient/Resident with Eating, dated 07/01/16 indicated, Procedures: 10. Sit down. Review of R2's Resident Face Sheet, located under the Resident tab of the electronic medical record (EMR), revealed R2 was admitted on [DATE] and had diagnoses including dementia. Review of R2's quarterly Minimum Data Set (MDS), located in the EMR under the RAI (Resident Assessment Instrument) tab with an Assessment Reference Date (ARD) of 12/27/22, revealed R2's Brief Interview for Mental Status (BIMS) score was not assessed due to the resident being rarely/never understood. This MDS also revealed R2 required total dependence during meals. During a dining observation on 02/07/23 at 12:01 PM, Certified Nursing Assistant (CNA)4 was observed standing over R2 while feeding the resident. R2 was seated in a Geri-chair in the assisted dining room at the time of observation. A chair was available in the assisted dining room for CNA4's use; however, CNA4 was observed for an eight-minute continuous period, to stand over the resident while feeding him. During an interview on 02/07/23 at 12:09 PM, CNA4 was observed walking out of the assisted dining room. When asked the proper way she should assist a resident to eat, CNA4 stated, I should be sitting down, not standing up. During a dining observation on 02/07/23 at 12:10 PM, CNA4 immediately returned to the assisted dining room and was again observed standing over R2 while feeding the resident. A chair remained available in the assisted dining room for CNA4's use; however, CNA4 was observed for a three-minute continuous period, to stand over the resident while feeding him. During an interview on 02/08/23 at 12:20 PM, the Social Services Director (SSD) stated, Staff should not stand or hover over the resident when feeding them. They [staff] should be at eye level. This is a dignity issue. During an interview on 02/08/23 at 4:18 PM, the Director of Nursing (DON) stated, The staff should sit when feeding resident. The staff should be at eye level because makes it more personable.

Based on observation, interview, record review, and facility policy review, the facility failed to honor choices regarding meals for 1 (Resident (R) 32) of 1 resident reviewed for dialysis out of a total sample of 21 residents. Specifically, R32's choice of receiving his lunch meal upon return from dialysis. Findings include: Review of facility policy titled, Meal Service for Residents out of Facility at Mealtime, dated 08/01/20, indicated, Meals will be provided to patients or residents who are unable to eat at their usual time or in their usual location. Review of R32's Face Sheet, located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with medical diagnoses including but not limited to end stage renal disease. Review of R32's quarterly Minimum Data Set (MDS), located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed an admission MDS with an Assessment Reference Date (ARD) of 11/04/22, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R32 was cognitively intact. Review of R32's Orders located in the EMR under the Resident tab, revealed the following order: Dialysis: [name of dialysis facility] T [Tuesday] - Th [Thursday] - S [Saturday]. During an initial screening interview on 02/06/23 at 7:56 AM, R32 stated, When I get back from dialysis, I'm hungry but have to wait for my dinner tray. When asked what time he usually returned from dialysis, R32 stated, Sometimes 3:00 PM and sometimes 4:00 PM and sometimes later. R32 further stated, I've been telling them about it for a long time but it's been bad for the last three months. Sometimes they tell me that they threw my lunch tray away. During an observation and concurrent interview on 02/07/23 at 4:53 PM, R32 was observed in his bedroom asking, Where's my lunch tray. Why can't I get my lunch tray? There was no staff observed to be in the area at this time of observation. When asked how long it had been since he returned from dialysis, R32 stated, I just got back about ten minutes ago. I always come back hungry. At this time of observation, dinner meal trays were being passed on other halls. Review of R32's Resident Progress Notes, from November 2022 - February 2023, located in the EMR under the Resident tab, documented R32's return to the facility on dialysis days ranged from the hours of 3:15 PM - 5:45 PM, with most of the return time being 4:30 PM. Review of R32's Resident Progress Notes dated 02/07/23, documented R32 returned to the facility at 4:45 PM. During an interview on 02/08/23 at 1:31 PM, Licensed Practical Nurse (LPN)3 stated that R32 returns from dialysis between 4:00 - 5:00 PM. LPN3 stated, When he returns, I usually get him a sandwich or something. LPN3 further stated, He was really upset yesterday and stated he wanted his lunch tray, but they didn't have one for him. It happens to him every dialysis day. We used to keep it down here on the unit, but when the new manager in the kitchen started, she said that the tray can't be held here. During an interview on 02/08/23 at 1:37 PM, LPN1 stated, The dietary manager informed us that the lunch trays could not be held on the unit. She said that it is against policy. Since we can't give him his lunch tray, we try to offer him a sandwich but he said that he wants his lunch. Usually, dinner is about to come when he gets back so he gets that but is really upset about not having his lunch. During a follow up interview with R32 on 02/08/23 at 1:39 PM, when asked if he had received his lunch tray on yesterday afternoon, R32 stated, No, I got my dinner tray, but I had to wait until after 5:30 PM for that. I should be able to get my lunch tray. This happens every Tuesday, Thursday, and Saturday. It happens every single time. During an interview on 02/08/23 at 2:22 PM, Cook1 stated, Dialysis residents' lunch trays are held on the unit until they return from dialysis. During an interview on 02/08/23 at 2:24 PM, Cook2 stated R32's lunch trays were held on the unit in the refrigerator. When he returns from dialysis, the staff warm it up. During an interview on 02/08/23 02:23 PM, the Dietary Manager (DM) stated she began working at the facility approximately one year ago. When asked about R32's lunch tray on dialysis days, the DM stated, If he is hungry after dialysis, the staff can come get his dinner tray early. The DM stated she was not sure if the staff knew R32's dinner tray could be requested early. The DM further stated, When I started, I told nursing they can't put the tray in fridge because it can't be re-heated properly using the microwave. It is also an infection control issue. By the time that he gets back from dialysis, we are making dinner. If he is hungry, they need to come to the kitchen and get his dinner tray. When asked if the resident can get his lunch tray upon return from dialysis, the DM stated, No, because it is already dinner time and dinner arrives on his hall between 5:15 PM and 5:30 PM. During an interview on 02/08/23 at 4:18 PM, the Director of Nursing (DON) states her expectation is for R32 to receive his lunch tray upon return from dialysis.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident (R) 64) of 1 resident reviewed for urinary catheter received appropriate catheter care out of a total sample of 21 residents. The facility's deficient practice had potential to injure R64's urinary tract system. Findings include: Review of facility provided policy titled Catheter - Urinary Catheter, Cleaning and Maintenance, revised 07/01/16, indicated, With non-dominant hand: B. Male: Retract foreskin, if not circumcised, and hold penis at shaft just below glans, maintaining position throughout the procedure. This policy further indicated, Cleanse area well at catheter insertion, taking care not to pull on catheter or advance further into urethra. Review of R64's Face Sheet located in the electronic medical record (EMR) under the Resident tab, revealed an admitted [DATE] with medical diagnoses that included obstructive and reflux uropathy (urine does not drain from the bladder). Review of R64's quarterly Minimum Data Set (MDS) located in the EMR under the RAI (Resident Assessment Instrument) tab, revealed an admission MDS with an Assessment Reference Date (ARD) of 12/30/22, revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15, indicating R64 was mildly cognitively impaired. Per this MDS, R64 had an indwelling catheter. Review of R64's Orders, located in the EMR under the Resident tab, revealed the following order: Indwelling foley catheter 16 fr [French] - 10 cc [cubic centimeter] bulb for obstructive and reflux uropathy. During an observation and concurrent interview on 02/08/23 at 11:37 AM, Certified Nursing Assistant (CNA) 3 was observed to complete catheter care for R64. CNA3 used a wet washcloth and started at the end of the resident's penis and cleansed the tubing. CNA3 did not hold R64's penis to prevent the tubing from being pulled tight. CNA3 was holding and pulling the tubing instead of holding R64's penis. There was no stat lock or leg strap observed. CNA3 did not clean R64's penis during this observation of catheter care. CNA3 stated was R64's primary caregiver and provided catheter care to R64 every shift that she worked. During an interview on 02/08/23 at 4:44 PM, when informed of the technique used by CNA3 during R64's catheter care, the Director of Nursing (DON) stated, The tubing should have been held to prevent pulling, the penis should have been cleaned, and there should have been a leg strap or clip.

Based on record reviews and interviews, the facility failed to conduct behavior tracking and monitor the side effects of antidepressant medication for 1 of 5 residents (Resident (R) 16) reviewed for unnecessary medications out of a total sample of 21 residents. These failures placed the residents at risk for not obtaining the intended therapeutic goal of the antidepressant medication and the potential for serious adverse effects from the antidepressant medications. Findings include: Review of R16's Face Sheet, located in the Resident tab of the electronic medical record (EMR), revealed R16 was admitted to the facility on [DATE]. R16's diagnosis included but was not limited to depression. Review of R16's Brief Interview for Mental Status (BIMS) in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/23, located in the RAI tab of the EMR, revealed a score of 14 out of 15 which indicated R16 was cognitively intact. Review of R16's Physician's Orders, dated 01/01/23 and located in the EMR under the Resident tab, revealed R16 received sertraline (an antidepressant) 25mg (milligrams) daily. Further review failed to reveal orders for behavior tracking and/or monitoring the side effects of antidepressant medications. Review of R16's Care Plan, updated 01/18/23 and located under the RAI tab in the EMR, documented Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, hypotension [low blood pressure], or anticholinergic symptoms [dry mouth, confusion, disorientation, poor coordination]. Review of R16's Medication Administration Records (MAR) and Treatment Administration Record (TAR), dated 09/2022 through 01/2023, located in the EMR, revealed no behavior tracking or medication side effects monitoring for antidepressant medications. During an interview on 02/08/23 at 2:45 PM, the Unit Manager (UM) stated there was no documentation of R16's behavior or medication side effects monitoring for the antidepressant medication. During an interview on 02/08/23 at 4:39 PM, the Director of Nursing (DON) stated the resident should have a template in her record that prompts the nurses to monitor behavior and side effects.

Based on observation, interview, record review, and policy review, the facility failed to decrease the dosage of a blood pressure medication when ordered by the physician for 1 resident (Resident (R) 55) of 5 residents reviewed for unnecessary medications out of a total sample of 21 residents. This deficiency had the potential for R55 to continue to experience unwanted side effects of a slow heart rate. Findings include: Review of the facility's policy Physician Orders revised 07/01/2016 documented, .Record the actual order received from the physician . Telephone and verbal orders are immediately recorded on patient's/resident's medical record . After initiating the steps to carry out the physician's written order (i.e entering it on the medication sheet, placing order with pharmacy, etc.), the nurse countersigns and dates the order. Review of R55's Face Sheet located in the Resident tab of the electronic medical record (EMR), revealed R55 was admitted to the facility on [DATE]. R55's diagnosis included but was not limited to; dementia, hypertension, long QT syndrome (a heart rhythm disorder) and acute embolism (artery blockage) of lower extremity. Review of R55's Brief Interview for Mental Status (BIMS) in the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/22, located in the RAI tab of the EMR, revealed R16 scored a 7 out of 15 which indicated R16 had severe cognitive impairment. Review of R55's Pharmacy Note to Attending Physician, located in the EMR under Documents tab and dated 12/26/22, revealed Resident is currently taking Quetiapine and Haloperidol [both are antipsychotic medications]. Concurrent use of these medications may lead to QT prolongation. Recommend obtaining an ECG [records the electrical signal from the heart to check for heart conditions] now and periodically to monitor for adverse effects. Review of R55's Cardiology Report, under the Documents tab in the EMR ordered by the Physician dated 12/30/2023, revealed Abnormal ECG Results: Moderate sinus bradycardia [slow heart rate]. Review of R55's Progress Notes, under the Resident tab located in the EMR, revealed on 01/02/23 the physician ordered a decrease in R55's Metoprolol (anti-hypertension medication) from 50 milligram (mg) twice a day to 25 mg twice a day because R55s ECG revealed moderate sinus bradycardia. Review of R55's Medication Administration History, located under Resident tab in the EMR revealed R55 received Metoprolol 50 mg, instead of 25mg, twice a day from 01/02/23 until 01/16/23. Review of R55's Progress Notes, under Resident tab located in the EMR, the physician noted that the orders to decrease R55's Metoprolol were not carried out. During a phone interview with the physician on 02/07/23 at 4:40 PM, the physician said, The patient had bradycardia, the medication order should have been followed through when I first ordered it. During an interview on 02/08/23 at 11:44 AM, the Director of Nursing (DON) said When the doctor verbally tells the nurse his order, that nurse should put in the order.

Based on review of the facility policy, record review, interviews, and observations, the facility failed to ensure residents were free from resident-to-resident abuse for 2 (Resident (R)1 and R6) of 6 sampled residents reviewed for abuse. This resulted in an incident of resident-to-resident abuse in which R6 was hit in the face and bitten by R5 on 09/19/22. Additionally, R1 was scratched on the chest during an incident of resident-to-resident abuse on 08/03/22 by R5. Findings include: Review of a facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, dated 10/01/20, revealed, The facility's leadership prohibits neglect, mental, physical and/or verbal abuse. The policy also indicated, 5. Ongoing assessment, care planning, and monitoring of those patients/residents with special needs that may lead to neglect is conducted, for example: A. History of aggressive behavior. B. History of entering other patient/resident rooms. Review of a Face Sheet revealed R5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge-return anticipated Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/11/22, revealed R5 was discharged to an acute hospital on 04/11/22. The MDS indicated R5 was severely impaired in cognitive skills for daily decision-making per a staff assessment of mental status and exhibited verbal and physical behavioral symptoms directed toward others and wandering behaviors on one to three days during the seven-day assessment period. Review of a Care Plan, dated 08/05/21, revealed R5 had the potential to have physical and verbal altercations with others. The care plan indicated the resident wandered in the hallways, into others' rooms, yelled at others, and refused care at times and was frequently redirected by staff. Interventions included: - One-on-one (1:1) supervision as needed - created 08/05/2021. - Redirect resident as needed, offer snacks, diversional activities as needed - created 08/05/2021. - Separate resident from other residents to ensure safety - created 02/07/22. - Avoid overstimulation, for example noise, crowding, other physically aggressive residents - created 02/10/22. Review of Resident Progress Notes, dated 06/02/22 through 07/27/22 revealed occasional episodes of agitation and combativeness with staff, but no resident-to-resident altercations. A Resident Progress Note dated 07/01/22 at 7:20 PM revealed R5 began getting combative at 6:00 PM. At 6:45 PM, the resident ripped down the COVID wall. Staff attempted to reorient the resident, but the resident was extremely combative. [MEDICATION(S)] [an antipsychotic medication] was administered at 6:50 PM. The resident began picking up drawers and trash cans and throwing them at staff. At 7:44 PM, the resident remained combative, and [MEDICATION(S)] (an antianxiety medication) was administered. Review of a Psychiatry Follow Up Note, dated 07/04/22, revealed R5 received a follow-up assessment and evaluation of psychiatric medications by the psychiatric mental health nurse practitioner (PMHNP). The note indicated staff reported the resident had periods of agitation and had combative behavior at times when treatments were given. The note indicated the resident was recently upset with staff and attempted to tear down the COVID wall and threw objects at people. The resident had yelled and screamed and thrown food and a tray at staff and on the floor. The note indicated the resident wandered the hallways and was difficult to redirect. Review of Resident Progress Notes, dated 07/09/22 at 6:31 PM, revealed R5 was wandering the hallways and going in and out of another resident's room. The resident was not easily redirected, and [MEDICATION(S)] was administered. Review of a Psychiatry Follow Up Note, dated 08/03/22, revealed R5 had periods of agitation and was combative at times. The note indicated the resident was in and out of other residents' rooms, taking things. Additionally, the resident was difficult to redirect and had periods of yelling out. The current medications included [MEDICATION(S)] (an antipsychotic medication) 20 milligrams (mg) twice daily, [MEDICATION(S)] 1 mg as needed, and [MEDICATION(S)] 25 mg twice daily. The Recommendations/Plan section of the note indicated the PMHNP recommended to consider increasing the resident's [MEDICATION(S)] (an antipsychotic medication) to 40 milligrams (mg) twice daily (the ordered dose as of 08/03/22 was 20 mg twice daily). Review of a quarterly MDS with an ARD of 08/25/22, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The MDS indicated the resident exhibited physical and verbal behaviors directed toward others, rejection of care, and wandering on one to three days during the seven-day assessment period. According to the MDS, the resident was independent with bed mobility and required only supervision with transfers, walking, and locomotion. 1. Review of a Face Sheet revealed R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS with an ARD of 09/15/22, revealed R1 had a BIMS score of 9, which indicated moderate cognitive impairment. The MDS indicated the resident exhibited no behavioral symptoms during the seven-day assessment period. According to the MDS, the resident was independent with transfers, required supervision with bed mobility, and used a walker for mobility. Review of a South Carolina Department of Health and Environmental Control (DHEC) Accident/Incident Reporting Form, dated 08/04/22, revealed that R1 reported during the night of 08/03/22, R1 was in bed, and the resident's roommate (R5) approached R1 and scratched R1 on the chest without provocation. Review of a South Carolina DHEC, Five-Day Follow-Up Report, dated 08/08/22, revealed the facility substantiated abuse, as R5 had physical contact with R1, resulting in scratches to R1. An attached email revealed R1 was moved to a different room and was doing fine and is much happier now. The email indicated R5 was left without a roommate to prevent further issues. The email revealed R1 had superficial scratches to the chest area that had now cleared. During an interview on 10/18/22 at 2:20 PM, Licensed Practical Nurse (LPN)1 stated she recalled the incident between R1 and R5. She indicated R5 was not happy about something and scratched R1 while R1 was lying in bed. During an interview on 10/18/22 at 2:40 PM, LPN2 indicated she recalled the incident when R5 scratched R1. She stated the incident was unprovoked and would be considered an assault. During an interview on 10/18/22 at 3:40 PM, the Director of Nursing (DON) stated she was not employed by the facility at the time of the incident between R1 and R5. During an interview on 10/18/22 at 4:30 PM, the Administrator stated she was not employed by the facility at the time of the incident between R1 and R5. Review of Resident Progress Notes, dated 08/04/22 through 09/13/22, revealed no evidence R5 was involved in any further resident-to-resident altercations until 09/19/22. 2. Review of a Face Sheet revealed R6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS, dated [DATE], revealed R6 had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS indicated the resident exhibited verbal behaviors toward others on one to three days during the seven-day assessment period. According to the MDS, the resident required extensive assistance with bed mobility and did not transfer, walk, or move between locations in the room or off the unit during the seven-day assessment period. Review of a South Carolina Department of Health and Environmental Control (DHEC) Initial 2/24-Hour Report, dated 09/19/22, revealed R5 was found in R6's room, and that R5 bit R6. There was no broken skin. R5 was placed on 1:1 supervision with a staff member. Review of a facility Falls Investigation Worksheet, dated 09/19/22 at 5:55 PM, revealed R6 began screaming. Staff responded and found R5 standing over R6 and biting R6's left arm and hitting R6 in the face. Three staff had to redirect and remove R5 from R6's room. R5 began to charge at staff and hit staff with a wet floor sign. [MEDICATION(S)] was administered to R5 and 911 was called at 6:03 PM. R5 continued to wander into other residents' rooms and staff continued to redirect the resident. Emergency Medical Services (EMS) arrived at 6:17 PM but refused to transport R5. Review of R6's Care Plan revealed a care plan problem was added on 09/20/22 to address R6's behavior of yelling out inappropriately. Interventions included to assess whether the resident's behavior endangered the resident due to other residents' inability to tolerate the yelling out and for staff to intervene if necessary. Additionally, when the resident began to yell out, staff were to provide comfort measures for basic needs, such as determining if the resident was in pain, hungry, required toileting, or was too hot/cold. Review of R5's care plan revealed an intervention to provide 1:1 supervision for all shifts was added and in effect from 09/20/22 through 09/29/22, after which the 1:1 supervision was to be continued on the 3:00 PM to 11:00 PM shift. Review of Resident Progress Notes, dated 09/19/22 through 10/17/22 revealed no further resident-to-resident altercations involving R5. On 09/25/22 at 3:06 PM, the notes indicated the resident attempted to approach a resident who had been screaming for help throughout the shift, but the 1:1 staff placed him/herself between the two residents to prevent an altercation from occurring. R5 was redirected back to the room to watch a movie. During an interview on 10/17/22 at 11:50 AM, R6 stated the resident remembered being assaulted by R5, who had entered the resident's room and tried to remove something from the bed. When R6 stated the item belonged to R6, R5 hit R6 multiple times in the face, then bit the resident's arm. R6 stated they had not seen R5 since that incident and were not worried about the resident coming back to the room. On 10/17/22 at 12:00 PM, R5 was observed lying on the bed in their own room. At 12:25 PM, the resident remained in bed. The resident's room was observed to be at the end of the hallway, behind the nurse's station, and separated from other residents' rooms. On 10/17/22 at 3:30 PM, R5 was observed seated on a chair beside the bed in their own room. A staff member was seated on a chair at the end of the bed. R5 was watching television and was calm. The surveyor spoke to the resident, and the resident's demeanor was calm and friendly. On 10/18/22 at 8:50 AM, R5 was observed lying on the bed, fully clothed and with eyes closed. On 10/18/22 at 11:30 AM, R5 was observed seated in a chair beside the bed, watching television. On 10/18/22 at 4:30 PM, R5 was observed watching television in the room with a staff member sitting in the room with the resident. During the survey from 10/17/22 through 10/18/22, R5 was not observed out of the room and did not exhibit any behavioral symptoms. During an interview on 10/18/22 at 1:15 PM, Certified Nursing Assistant (CNA)1 stated R5 was calmer now. CNA1 stated the resident had a sitter now and that the resident's medication had been changed. CNA1 indicated loud noises triggered the resident and that was why the incident with R6 occurred. During an interview on 10/18/22 at 2:40 PM, LPN2 stated she recalled the incident when R5 bit R6. LPN2 stated R5 was unprovoked, and that the incident would be considered an assault. During an interview on 10/18/22 at 3:00 PM, the Social Services Director (SSD) stated that following the incidents involving R5, she interviewed residents who resided near where the incidents had occurred, and the residents did not express any concerns/fears for their safety. The SSD stated the situation with R5 was difficult because of family dynamics and the inability to have the resident transferred to a different level of care. During an interview on 10/18/22 at 3:40 PM, the Director of Nursing (DON) stated both incidents involving R5 were considered assault. The DON further stated the facility had put preventive measures in place that had been effective, including putting her in a room that was away from other residents and near the nurse's station and having 1:1 supervision on the 3:00 PM to 11:00 PM shift. She indicated the staff were aware that if the resident came out of the room, they were to watch the resident. During an interview on 10/18/22 at 4:30 PM, the Administrator stated she and the staff were all aware of R5's behaviors and had interventions in place to reduce the risk of R5 being aggressive toward other residents.

Based on interviews, document review, and facility policy review, the facility failed to develop and implement an abuse policy which included reporting suspicion of crimes to local law enforcement for 3 (Resident (R)2, R5, and R4) of 3 sampled residents who were alleged and/or witnessed to have been perpetrators of resident-to-resident abuse. Specifically, the facility failed to notify local law enforcement authorities when R5 scratched R1 and hit and bit R6; when R2 hit R1; and when R4 hit R3. Findings include: Review of a facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, dated 10/01/20, revealed Report to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. There was no directive to contact local law enforcement for suspicion of crimes. On 10/19/22, the Administrator provided a second, undated, facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment. The Administrator stated the policy was revised on 10/07/22. The policy did not provide direction to report to local law enforcement authorities for suspicion of a crime. During the survey process, between 10/17/22 and 10/18/22, four incident reports involving resident-to-resident physical abuse, involving six residents, were reviewed with the following findings: - On 08/04/22, R1 alleged that R5 scratched R1 on the chest without provocation during the night of 08/03/22. - On 09/05/22, R4 hit R3 in the face. - On 09/18/22, R1 alleged R2 hit R1 in the face. - On 09/19/22, staff witnessed R5 hitting and biting R6. There was no evidence the facility notified local law enforcement authorities regarding any of the four incidents. Refer to F608 and F609 for further details. During an interview on 10/18/22 at 3:40 PM, the Director of Nursing (DON) stated she was unaware of the requirement to contact law enforcement for suspicion of a crime. The DON stated if a resident struck another resident, it could be considered assault. During an interview on 10/18/22 at 4:30 PM, the Administrator stated the incidents involving residents striking residents without provocation would be considered assault. The Administrator further stated she was unaware of the requirement to notify law enforcement agencies when an assault occurred.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure an allegation of resident-to-resident physical abuse was immediately reported to the Administrator and the State Survey Agency (SSA) for 1 Resident (R)1 of 6 sampled residents reviewed for abuse. Findings include: Review of a facility policy titled, Abuse, Neglect, Exploitation, or Mistreatment, dated 10/01/2020, revealed, Report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not result in serious bodily injury. Report to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Review of a Face Sheet revealed R5 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/25/22, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. The MDS indicated the resident exhibited physical and verbal behaviors directed toward others, rejection of care, and wandering on one to three days during the seven-day assessment period. According to the MDS, the resident was independent with bed mobility and required only supervision with transfers, walking, and locomotion. Review of a Face Sheet revealed R1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS, dated [DATE], revealed R1 had a BIMS score of 9, which indicated moderate cognitive impairment. The MDS indicated the resident exhibited no behavioral symptoms during the seven-day assessment period. According to the MDS, the resident was independent with transfer, required supervision with bed mobility, and used a walker for mobility. Review of a South Carolina Department of Health and Environmental Control (DHEC) Accident/Incident Reporting Form, dated 08/04/22, revealed that R1 reported that during the night of 08/03/22, R1 was in bed, and the resident's roommate (R5) approached R1 and scratched R1 on the chest without provocation. Review of a Patient/Resident Incident/Accident Investigation Worksheet revealed the incident occurred on 08/03/22 at 8:00 PM. The Social Services Director (SSD) was notified of the incident on 08/04/22 at 7:30 AM, and the initial 2-hour report to the State Survey Agency was submitted on 08/04/22 at 9:13 AM, as confirmed by the time stamp on the fax confirmation. During an interview on 10/18/22 at 2:20 PM, Licensed Practical Nurse (LPN)1 stated any type of abuse, witnessed or reported, was to be immediately reported to the Administrator or Director of Nursing (DON). LPN1 further stated the nurse on duty was to report the abuse, initiate an incident report, and notify the family and physician. LPN1 stated nursing was not responsible for submitting a report to the State Survey Agency and that the follow-up investigation was conducted by the DON and Social Services. LPN1 acknowledged she was on duty on the night R5 scratched R1. LPN1 stated she separated the residents, moved R1 to another room, and did the necessary notifications. LPN1 stated the nurse working with her that night contacted the next in line. LPN1 indicated she did not remember who that was, as the facility did not have a DON at the time the incident occurred. LPN1 stated once the notifications were completed and the residents were safe, she did not do anything else. During an interview on 10/18/22 at 2:40 PM, Unit Manager LPN2 stated all abuse was to be reported to the Administrator or DON and a progress note was to be completed. LPN2 stated nursing had two hours to notify leadership, the families, and the physician. Nursing would determine what had occurred by talking to the residents but then the information was submitted to Social Services for follow-up and investigation. LPN2 stated her main responsibility was to notify the Administrator within two hours, then the Administrator would come in and complete the report to the State Survey Agency. LPN2 stated she remembered the incident between R5 and R1. She indicated she received a call from one of the nurses around 9:00 PM and instructed the nursing staff to complete the documentation and notify the families. LPN2 revealed when she came in the next morning, she saw that the documentation was not completed and asked the Social Services Director (SSD) to report to the State Survey Agency. LPN2 stated the report to the state was late and should have been submitted the night before. During an interview on 10/18/22 at 3:00 PM, the SSD stated the Administrator needed to be contacted immediately for any type of abuse, whether witnessed or suspected. She indicated the Administrator submitted the abuse reports to the State Survey Agency. The SSD stated nursing staff were required to complete the incident worksheet, conduct a body audit, and initiate vital sign checks if necessary. During an interview on 10/18/22, the DON stated she had been employed with the facility for only two months. She indicated the process for abuse was for the nurse to make sure the residents were safe and medically okay, then contact the DON or Administrator immediately, so the Administrator could complete and submit the report to the State Survey Agency. The DON stated the Administrator conducted the abuse investigations, and that the DON had no role in reporting or investigating incidents of abuse. The DON asserted she was not able to provide any information regarding the 08/03/22 incident between R5 and R1, as she was not employed by the facility at that time. During an interview on 10/18/22 at 4:30 PM, the Administrator stated she was responsible for all reportable incidents and the corresponding investigations. She expected the staff to contact her immediately when there was an incident of abuse so she could submit the report to the State Survey Agency within the two-hour period. The Administrator indicated she was unable to provide any information regarding the 08/03/22 incident between R5 and R1, as she was not employed by the facility at that time.

Based on review of facility policy, record review, and interviews, the facility failed to ensure Resident (R)6 was served meals in accordance with allergies, intolerances, and preferences for 1 of 2 residents reviewed for Nutrition. Specifically, the facility served R6 shrimp, which had the potential of resulting in a life threatening incident. Findings include: Review of the facility's policy titled, Nutrition dated 08/01/20, revealed The Nutrition Service Director (NSD) or designee is responsible for training culinary staff on how to handle foods to avoid any inappropriate foods being served to patients or residents with food allergies. This may include special designated food preparation space in the case of life threatening food allergies. If using the MEALTRACKER computerized tray tickets, the word allergic to may be printed on the ticket using dietary notes, as well as recorded in the allergy section of the system. Food allergies are clearly communicated to culinary personnel. The facility admitted R6 on 10/07/20, with diagnoses included but not limited to; Alzheimer's disease, dysphasia, anaphylactic shock, and heart disease. Review of R6's Face Sheet located in the Electronic Medical Record (EMD) indicated R6 had known allergies to; Donzepil (medication used to treat Alzheimer's disease), seafood, shrimp, and shellfish. Review of R6's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/22 revealed R6 has a Brief Interview for Mental Status (BIMS) score of 0 out of 15, which indicates R6 is rarely or never understood. Review of R6's Care Plan dated 04/08/22, located in the EMR, revealed R6 has moderately impaired vision and is allergic to Donzepil, seafood, shellfish, and shrimp. Review of R6's Progress Note dated 06/10/22 revealed, Director of Nursing was called to the room by CNA because [R6] was throwing up. While entering the room resident vomited on himself. After checking [R6's] vital signs, lung sounds was assessed. It was discovered that [R6] had received food during lunch time that had shrimp on it. It was noticed that resident had allergies to seafood, shrimp and shellfish. Nurse Practioner was notified and ordered [R6] to have a one time dose of Benadryl 25mg, to do neuro checks and monitor for any reactions. Resident's sister was notified of incident and DON. Review of R6's Progress note dated 08/19/22 revealed, Review of Residential Progress Note dated 8/19/22 (but late entry on 8/22/22) states on Friday 8/19/2022 after lunch, resident was sent out to ER after eating shrimp which he is allergic. Unit Manager was notified and two 25mg tabs of Benadryl was administered. Physician Assistant was notified in the building and she went to evaluate. Resident starting swelling and he is semi-verbal but could not express himself. Two more 25mg Benadryl and 20 mg Pepcid was administered. Resident's family was notified. Review of R6's Meal Ticket for multiple dates revealed R6 in on a mechanical altered diet and has allergies to chocolate, seafood, shrimp, shellfish, and fish. Review of the facility's week at a glance menu for week 1, revealed the following food items were served on Friday; shrimp scampi, spinach salad, oatmeal peanut bar, fresh baked roll, and roasted red potatoes. Further review of the facility's menu did not indicate any other days that shrimp was served. In an interview on 09/08/22 at approximately 12:50 PM with the Kitchen Manager (KM), revealed she was aware R6 had received shrimp on his meal tray on 08/19/22. The KM stated the Cook did not read the ticket. It says alternate food, she failed to follow through. The KM further stated, this is an ongoing process and they keep reminding workers to review the ticket. In an interview on 09/08/22 at approximately 12:56 PM with Cook (C1), revealed she is responsible for serving and plating food. C1 verified R6 had shrimp on his meal plate (during the day of the incident). C1 further stated she is aware that R6 is allergic to shrimp and followed up with, It was busy. I made a mistake. I went to see if [R6] ate it and asked another CNA if she saw his tray. I told them I made a mistake and gave him shrimp. C1 concluded that later R6 had a reaction (itching and scratching) and the nurse gave him an allergy pill. An attempted interview on 09/08/22 at approximately 4:26 PM with R6 was unsuccessful. In an interview on 09/08/22 at approximately 4:28 PM with the Administrator, revealed she was aware of the incident and the kitchen was ultimately responsible. The Administrator stated she was walking down the hall and saw staff around R6. She asked what happened and someone said he (R6) was having a reaction. They decided to send him out to the hospital. The Administrator further stated he couldn't communicate and they called 911. Follow up with the kitchen revealed C1 admitted she served him shrimp. The Administrator concluded the kitchen is ultimately responsible and should have known he is allergic.

Based on record review, interview, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) Assessment was transmitted within 14 days of completion for 14 of 30 Sampled Residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #7, Resident #8, Resident #16, Resident #17, Resident #18, Resident #25, Resident #26, Resident #28, and Resident #44) whose assessments were reviewed. Findings include: Review of the facility's MDS - Primary Assessment Policy revised 10/1/19 revealed: .5. Complete a comprehensive assessment .F. MDS Nurse to close the assessment after the VB4 date (date of the signature of the person completing the care planning decision on the RAP summary sheet) has been entered and no later than seven (7) days after the VB2 date (date of the RN assessment coordinator's signation, indicating that the MDS is complete). And transmit every seven (7) days. .6. MDS completion guidelines for quarterly review of resident status: .E. MDS Nurse to close the assessment no later than seven (7) days after the R2b date (date of the RN assessment coordinator's signation, indicating that the MDS is complete). Review of the facility's MDS - Automation/Electronic Submission Policy revised 10/1/2019 revealed Policy: The facility will electronically submit via Matrix its state - specific version of the Minimum Data Set (MDS) within the required timeframes according to applicable law and regulations. Review of Resident #1's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed pending signature for sections GG and Z. There were no signatures for the other sections. There was no RN (Registered Nurse) signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #1's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #2's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #2's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #3's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed status: in progress. Further review of Section Z: Assessment Administration revealed no signatures sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #3's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #4's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections A - J and sections L - Q. There was no RN signature verify assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #4's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #5's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #5's Quarterly MDS assessment dated /21/21 was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #7's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #7's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #8's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections A - J and sections L - Q. There was no RN signature verify assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #8's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #16's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #16's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #17's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #17's Significant Change MDS assessment dated [DATE] revealed status: in progress. Further review of Section Z: Assessment Administration revealed no signatures for sections B, F, G, K, L and M. There were pending signature for sections A, D, GG, H, I, J, N, O, Q and Z. There were no RN signature verifying assessment completion. The Significant Change MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #17's Significant Change MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #18's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #18's Quarterly MDS assessment dated [DATE] revealed status: in process. Further review of Section Z: Assessment Administration revealed no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #18's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #25's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #25's Quarterly MDS assessment dated [DATE] revealed status: in progress. There were no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #25's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #26's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #26's Quarterly MDS assessment dated [DATE] revealed status: in progress. There were no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #26's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #28's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #28's Quarterly MDS assessment dated [DATE] revealed status: in progress. There were no signatures for sections completed. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #28's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). Review of Resident #44's electronic Face Sheet revealed the resident was admitted to the facility on [DATE] and discharged to the hospital on 8/4/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #44's Quarterly MDS assessment dated [DATE] revealed status: in progress. There were no signatures for sections A, B, C, D, E, G, GG, H, I, J, L, M, N, O, P, and Q. There was no RN signature verifying assessment completion. The Quarterly MDS was not transmitted. Review of the facility's CMS (Center for Medicare and Medicaid Services) Submission Report - MDS 3.0 NH (Nursing Home) Final Validation Report dated 8/13/21 revealed Resident #44's Quarterly MDS assessment dated [DATE] was accepted with the following warning: Assessment Completed Late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). During an Interview on 8/12/21 at 4:35 p.m. with the DON, MDS Nurse and the Administration, the following was revealed: Per the MDS Nurse, revealed he/she began working at the facility on 7/12/21 which was about a month and responsible for completing the MDS Assessments and the Care Plans. He/she stated was unsure why the mobile MDS Nurse did not sign and transmit the MDS Assessments and will get the assessments signed and transmitted, then will provide a copy of the transmission report. Per the Administrator, he/she stated the previous MDS Nurse left on March 12, 2021, and the facility had a mobile MDS Nurse until the current staff member started. When he/she started in April, all the Administrative Staff were interims. He/she stated when the current MDS Nurse arrived, the first thinghe/she did was ran a 60-day report to determine which assessments needed to be completed. The MDS Nurse agreed that is what he/she did. The Administrator stated the MDS Nurse was currently working to get them all completed plus complete the assessments that are due. Per the DON, the facility has MDS and Care Plan policies. He/she stated the facility also references the RAI (Resident Assessment Instrument) Manual 3.0.

On the days of the Complaint Inspection, based on record review, interviews and review of facility files, the facility failed to provide appropriate supervision to prevent falls for 1 of 4 residents with a history of seizures. Resident # 1 was left unattended in the bathroom, had a seizure and fell from the toilet, which resulted in a cervical fracture. The findings included: Resident #1 sampled as a result of a facility reported incident that alleged s/he was a fall risk who sustained a cervical fracture when left unattended in the bathroom. Review of Resident #1's current medical record and the facility investigation revealed that the facility failed to provide adequate interventions to prevent injury when the resident was left in the bathroom unattended on 12/14/2012. The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed notes written on 12/14/12 that documented, 10:30 AM: "Resident was participating in PT (Physical Therapy) Began to have seizure activity. Lasted for about 5 (five) sec. (seconds). Placed in the bed..." 1:40 PM: Res. (resident) was discovered in floor in his/her room by his/her nurse. S/he was lying parallel to the left side of the bed... A&O (alert and oriented) X 3. 4:15 PM: "Res. transported to _____(Hospital) d/t (due to) fall and laceration to left side of head. Res. was discovered by this nurse in the restroom; seizing on his/her left side. Blood was noted coming from his/her left side of his/her head..." Nurse's Note of 12/20/12, 5:15 PM : Resident returned to facility from hospital via w/c (wheel chair)... Has [DIAGNOSES REDACTED]. Seven stitches noted to L side of forehead. Bruise noted to R forearm. Three scabs noted to top of right hand..." Review of the Hospital Discharge Summary dated 12/20/12 revealed a Discharge [DIAGNOSES REDACTED]. Generalized tonic-clonic seizures. 2. Fall with resultant cervical fractures at C 1 and C 5. 3. Urinary Tract Infection..." History of Present Illness: "...Today at the nursing home, the patient was noted to have a seizure followed by loss of consciousness and hit his head with lacerations on his forehead... CT spine did show nondisplaced acute fracture of anterior and inferior endplate of C 5 with minimally displaced acute fractures in the right lateral mass of C 1." In an interview with the surveyor on 1/15/2013 at approximately 5:30 PM, the Occupational Therapist (OT) confirmed the resident had a seizure earlier in the day of 12/14/12 while in therapy. S/he stated the resident slid from the bed while eating lunch earlier in the day. "We gave him the pressure pad at the time and put the strips down. S/he had problems with voiding before. S/he was acting like s/he did when s/he had a urinary tract infection. The nurse was aware of the behaviors." In a telephone interview with the surveyor on 1/22/13 at approximately 11:15 AM, Registered Nurse #1, stated the resident had a seizure in therapy during the morning. S/he stated s/he had a history of [REDACTED]. Around lunch the resident slipped off the bed. Later in the day OT (occupational therapy) was working with the resident and assisted him with the urinal. "S/he did not want anyone around when s/he was using bathroom... After 3, I was in the room with connecting bathroom. I heard a crash and went into bathroom and s/he was lying on the floor seizing. I opened the door to yell for assistance. The 3-11 CNA (#1), said s/he was trying to find me because s/he was yelling at her/him to get out of bathroom. S/he had been left in bathroom alone before. S/he was alert and knew how to use the call light." The nurse was not aware if the CNA knew the resident had a seizure and a fall earlier in the day. Certified Nursing Assistant (CNA) #1 was interviewed by the surveyor on 1/16/13 at approximately 11:10 AM. The CNA stated, "I came on duty at 3:00 PM... I took Resident #1 to the bathroom s/he stood up and pulled his/her clothes down and told her/him to shut the door. I went to find the nurse because s/he was upset, s/he didn't want the alarms. S/he was not his/her normal self... The nurse was in the room next door to the resident's, s/he heard him/her when he/she had the fall. S/he went in the bathroom and saw him/her on the floor... The nurse said s/he had a seizure... I didn't know s/he had a seizure earlier or that s/he had fallen prior to that incident. Normally the CNA who has them on day shift gives report on the residents. That CNA was already gone that day... I normally wouldn't leave the room, I would do something in room. I left that day to get the nurse cause s/he was so upset." Review of the care plan in use at the time of the fall dated 10/2/2012 and last updated 12/12/2012 revealed the resident was at risk for falls. Interventions included, alarm to bed and chair, resident education for safety issues, and falling star program. On 12/14/2012 the care plan was updated related to the resident's preference for privacy when using the restroom. Interventions included "...2. If resident is in the restroom staff is not to leave the room. 3. Staff is to stand beside door while resident is in the restroom." Seizure Disorder was care planned on 10/3/2012 and last updated 12/12/2012. Interventions included "1. Monitor for signs and symptoms of seizures...; 2. If seizure occurs, provide safety as able... 5. Provide safe environment per policy. 6. M-side rails..." Review of the CNA (Certified Nursing Assistant) Care Cardex Worksheet revealed the resident was to have "M" rails, alarm to bed and chair, Non skid strips at bedside. C-Collar at all times remove during care. Do not leave in bathroom unattended." There was nothing documented regarding the resident's seizure activity or history. The entries were not dated when added to the Worksheet.

On the days of the survey, based on record review and interview, the facility failed to to identify issues with respect to which quality assessment and assurance activities are necessary; and develop and implement an appropriate plan of action to correct identified concerns. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-520 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12. The facility was aware of resident and staff reported concerns but failed to fully explore the full outcome and consequences of the reported behavior. Additionally, the facility failed to develop an action plan to identify and or prevent reoccurrence. The findings included: During an interview on 12/5/12 at approximately 3:30 PM, the Nursing Home Administrator stated that Certified Nursing Assistant #1 (CNA) had reported on the morning of 11/12/12 at the end of her shift that there had problems over the week-end with Licensed Practical Nurse (LPN) #1, assigned to the Stone Unit. The Administrator further stated that s/he investigated and found that LPN #1 had signed off all the medications and completed the documentation necessary and had not investigated further. S/he was not aware of any other problems until Resident #10 reported that he/she had to wait several hours to get his/her medications and that the nurse was not doing her/his job per his/her facility-obtained statement. The Administrator further stated that s/he had reviewed camera videos to verify that LPN #1 had been out of the building as reported only for the time frame of 11/9/12 through 11/12/12. S/he stated that s/he felt that was enough information to terminate LPN #1 and had not reviewed any other time frames. The Administrator also stated that all staff had been instructed in the past to call her/him if they didn't get an appropriate response from the on call nurse and had provided the cell phone number for them to contact. S/he further stated that s/he couldn't say if the on call nurse's response was appropriate without further investigation. The Administrator stated that the concerns reported by the CNA and Resident #10 had not been taken to the Quality Assessment and Assurance committee and that the facility had not implemented a plan of action related to the deficiencies cited at F-281 or F-309. Cross Refer 483.20(k)(3) F-281 Professional Standards related to LPN #1 leaving her/his assigned unit multiple times during her/his shifts for extended periods leaving Stone Unit unattended by a nurse. In addition, when CNA #1 reported to LPN #1 that Resident #10 was "yelling" that he/she was in pain, LPN #1 instructed CNA #1 to administer Resident #10's medications, which were in a medicine cup on top of the medication cart while the nurse was out of the building. Cross Refer 483.25 F-309 Quality of Care related to residents being at risk for harm due to the LPN #1 being absent from Stone Unit multiple times during her/his shifts. Resident #18 experienced an episode of [DIAGNOSES REDACTED] with a Finger Stick Blood Sugar of 21 while the LPN #1 was out of the building leaving Stone Unit unattended. The nurse from Rogers Unit responded to the Certified Nursing Assistant's (CNA) request for help, leaving Rogers unit unattended for at least an hour and placing those residents on Rogers Unit at risk while s/he attended to the emergency on Stone Unit. In addition, Resident #10 reported that he/she was in pain and did not receive his/her pain medication for several hours. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-520 was lowered to a Scope and Severity of "F".

On the days of the Recertification Survey and Complaint Inspection, the facility failed to provide services that meet professional standards of practice. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents unattended, sometimes for extended periods. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-281. Immediate Jeopardy existed in the facility on 11-11-12 related to the actions of facility staff as noted above. The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed the facility had reported to the State agency that LPN #1 had been absent from her assigned unit multiple times during her shifts from 7:00 PM on 11/09/12 to 7:00 AM on 11/12/12. The report revealed the facility had camera videos and a time line was developed for LPN #1 during that time period and included a copy of the time line. Review of the time line revealed LPN #1 left the building 9 times between 7:00 PM and 7:25 AM on 11/09/12: 8:17 PM, 8:35 PM, 9:31 PM, 9:33 PM, 10:25 PM, 1:15 AM, 2:35 AM, 3:21 AM, and 5:09 AM. In addition, LPN #1 was seen coming back into the building at 4:30 AM but the facility was unable to determine when s/he exited. On 11/10/12, s/he exited the building 12 times that the exit and entrance times could be determined: 7:07 PM, 8:02 PM, 9:10 PM, 10:09 PM, 10:45 PM, 11:03 PM, 11:57 PM, 1:21 AM, 2:08 AM, 3:20 AM, 3:55 AM,and 6:49 AM. Additionally, at 4:59 LPN #1 was seen exiting the building. LPN #1 was not seen re-entering the building and was visualized at the dumpster at 6:08 AM and 6:20 AM and re-entered the building at 6:31 AM. On 11/11/12, LPN #1 did not clock in or out per the facility's time line. LPN #1 exited the building at 8:40 PM, 10:19 PM, 11:14 PM, 12:41 PM, 1:28 AM, 1:58 AM, 2:13 AM, 5:41 AM, and 6:20 AM. In addition, LPN #1 was seen on the video entering the building at 6:55 AM but the facility was unable to determine when she exited. Further review of the Follow-up Report indicated that Resident #10 voiced a complaint to the facility on [DATE] that he/she did not see the nurse, LPN #1, all night. The facility's report indicated the nurse asked if the resident was ready for his/her medication at 11:10 PM on 11/11/12 but the resident did not receive them until the following morning at approximately 6:15 AM The report further indicated that Resident #10 stated that LPN#1 sent CNA #1 in the room with the medications. The facility's investigation indicated that the CNA told Resident #10 that the nurse was not in the building. Resident #10 could not be interviewed during the Survey as s/he was transferred to the hospital at 8:00 AM on 12/4/12. Review of CNA #1's facility-obtained statement indicated that LPN#1 "was outside most of the night." CNA #1 revealed in his/her statement "I had residents yelling for their meds. ...Resident in room (number) was yelling repeatly (sic) yelling I am in pain my body feel like it's cracking in half please can I have my meds (and) tell the nurse to please come and please bring my meds (medications)." CNA #1 stated s/he located LPN #1 outside but was told by the LPN that s/he couldn't come in right then. The CNA's statement indicated LPN #1 said s/he already had the medications ready and would the CNA please take them to Resident #10. CNA #1 also indicated in her/his statement that s/he had called the Nurse from Rogers Unit to assist with an emergency with a resident. During an interview on 12/5/12 at 7:35 AM, CNA #1 confirmed the accuracy of her/his statement and added that LPN #1 "did take a lot of cigarette breaks." CNA #1 also stated that when s/he gave Resident #10's medications, there were 3 or 4 pills in the medicine cup and s/he did not know what they were. CNA #4 also gave a written statement to the facility that stated s/he had worked on Rogers Unit on 11/10-11/11/12 on the 11:00 PM to 7:00 AM shift. S/he indicated that the Stone Unit "CNAs kept coming over on Rogers to get the nurse to come over there because they couldn't find their nurse.' S/he further stated that caused LPN#2 "to get behind in (her/his) work." Further review of the Reportable file revealed a statement from LPN #3 that sometime after 7:00 PM on 11/10/12, LPN #1 texted LPN #3 to bring the medication cart keys outside to her/him so that LPN #3 could leave. LPN #3 refused and instructed LPN #1 to come to the unit to count the narcotics and to receive report. In an interview on 12/4/12 at 4:25 PM LPN #3 confirmed the accuracy of his/her statement and had no other information to offer. Additional review of the Reportable file indicated a statement had been obtained from Registered Nurse (RN) #1 who had worked 7:00 PM to 7:00 AM on 11/10/12. RN #1's statement indicated the CNAs on Stone Unit had voiced "concerns about finding the nurse on that side." RN #1 indicated that s/he texted the on-call nurse between 2:00 and 3:00 AM about the CNAs concerns and that numerous times throughout the night the CNAs were "searching for the nurse." During an interview on 12/5/12 at 10:05 AM, the Interim Director of Nursing (IDON) confirmed that s/he had been on call the week-end of 11/9 through 11/11/12. S/he stated s/he had received a text stating the CNAs were having trouble finding the nurse on the Stone Unit. The IDON stated that s/he texted LPN #1 and asked where s/he was. LPN #1 texted the IDON that s/he was in the bathroom. S/he also stated that s/he received a call when a resident was transferred out of the facility and called back to the facility but did not get an answer. S/he texted LPN #1 who texted back and said that s/he had been busy with the resident who had been sent out and had not been able to answer the phone when the IDON called. The IDON also stated that when s/he asked LPN #2 what had happened over the weekend, LPN #2 informed her/him that s/he had already reported everything to either the Administrator or the DON at that time, but s/he could not recall to whom s/he had reported. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-281 was lowered to a Scope and Severity of "F".

On the days of the Recertification Survey and Complaint Inspection, based on record review, interviews, and review of the facility's files made in reference to a complaint received by this office, the facility failed to provide care and services in a manner that reduced the residents' risk for harm. Licensed Practical Nurse (LPN) #1 left her/his assigned unit, Stone Unit, multiple times during her/his shifts from 7:00 PM on 11/9/12 through 7:00 AM on 11/12/12 leaving the residents on that unit unattended. Certified Nursing Assistants (CNA) were unable to locate the nurse assigned to the unit when Resident #18 was found unresponsive requiring LPN #2 from Rogers Unit to leave her/his unit unattended for a period of 1 hour to respond to the emergency on Stone Unit. In addition, a Reportable Incident was received by this office that unidentified medications were administered to Resident #10 by a Certified Nursing Assistant (CNA), not the staff nurse, following the residents repeated request for pain medications. On 12-18-12 at 10:35 AM the Administrator was notified that Substandard Quality of Care and Immediate Jeopardy was Identified at F-309. The Substandard Quality of Care and Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services The findings included: On 12/4/12 at approximately 3:15 PM review of the Five-Day Follow-up related to a Facility Reported Incident received by this office revealed a statement from LPN #2 on 11/13/12. LPN #2 indicated in the statement that s/he was called from her/his assignment on Rogers Unit to Stone Unit on 11/11/12 (actually AM of 11/12/12) by a CNA (Certified Nursing Assistant) who informed her/his there was something wrong with Resident #18. Upon entering the room at 3:00 AM, the resident was found unresponsive. LPN #2 checked the residents's blood sugar and found s/he had a critically low level of 21. The statement further stated that the primary nurse for Stone Unit returned to the floor from outside at 4:05 AM. The LPN's statement indicated that the primary nurse, upon return to the unit, asked LPN #2 why s/he didn't come and get her/him and LPN #2 told her/him there had not been time because the resident was critical. In an interview on 12/5/12 at 7:55 AM, LPN #2 confirmed the accuracy of her/his statement. S/he added that s/he had also been called over to Stone Unit to remove a pressure dressing from a [MEDICAL TREATMENT] site on 11/11/12. LPN #2 also stated that s/he had heard that it had been a problem for the CNAs on Stone to find LPN #1 but had never before been called over to take care of residents. S/he also stated that s/he did not call the on-call nurse as the crisis with Resident #18 had been handled. Further review of the Follow-up Report indicated that Resident #10 voiced a complaint to the facility on [DATE] that he/she did not see the nurse, LPN #1, all night. The facility's report indicated the nurse asked if the resident was ready for his/her medication at 11:10 PM on 11/11/12 but he/she did not receive them until the following morning at approximately 6:15 AM The report further indicated that Resident #10 stated that LPN#1 sent CNA #1 into the room with the medications. S/he had instructed the CNA that the medications she had previously poured were on the top of the medication cart and the CNA should administer those medications to the resident. The facility's investigation indicated that the CNA told Resident #10 that the nurse was not in the building. The facility's report also indicated that Resident #10 stated s/he was crying in pain and that s/he rated his pain as "9". Resident #10 could not be interviewed during the Survey as s/he was transferred to the hospital at 8:00 AM on 12/4/12. Review of CNA #1's facility-obtained statement indicated that LPN#1 "was outside most of the night." CNA #1 revealed in his/her statement "I had residents yelling for their meds. (medications) ...Resident in room (number) was yelling repeatly (sic) yelling I am in pain my body feel like it's cracking in half please can I have my meds (and) tell the nurse to please come and please bring my meds." CNA #1 stated s/he located LPN #1 outside but was told by the LPN that s/he couldn't come in right then. The CNA's statement indicated LPN #1 said s/he already had the medications ready (previously poured) and would the CNA please take them to Resident #10? Per the nurses instructions, the CNA then administered a cup of medications found on top of the medication cart to the resident. CNA #1 also indicated in her/his statement that s/he had called the Nurse from Rogers Unit to assist with an emergency with a resident. During an interview on 12/5/12 at 7:35 AM, CNA #1 confirmed the accuracy of her/his statement and added that LPN #1 "did take a lot of cigarette breaks." CNA #1 also stated that when s/he gave Resident #10's medications, there were 3 or 4 pills in the medicine cup and s/he did not know what they were. Additional review of the Reportable file indicated a statement had been obtained from Registered Nurse (RN) #1 who had worked 7:00 PM to 7:00 AM on 11/10/12. RN #1's statement indicated the CNAs on Stone Unit had voiced "concerns about finding the nurse on that side." RN #1 indicated that s/he texted the on-call nurse between 2:00 and 3:00 AM about the CNAs concerns and that numerous times throughout the night the CNAs were "searching for the nurse." CNA #4 also gave a written statement to the facility that stated s/he had worked on Rogers Unit on 11/10-11/11/12 on the 11:00 PM to 7:00 AM shift. S/he indicated that the Stone Unit "CNAs kept coming over on Rogers to get the nurse to come over there because they couldn't find their nurse.' S/he further stated that caused LPN #2 "to get behind in (her/his) work." A statement was also obtained by the facility from LPN #5 that indicated s/he worked on the day after the incident. S/he indicated that one one resident stated "she (LPN # 1) stayed outside all night long" and that LPN #1 "wouldn't give me my medicine." S/he further indicated that Resident #10 also informed her that LPN #1 "didn't do her job, s/he didn't give me my meds, other residents were banging on walls." Review of the Five Day Follow-up report revealed the facility had camera videos and a time line was developed for LPN #1 from 7:00 PM 11/09/12 through 7:00 AM 11/12/12. The facility provided a copy of the time line with the report. Review of the time line revealed LPN #1 left the building 9 times between 7:00 PM and 7:25 AM on 11/09/12: 8:17 PM, 8:35 PM, 9:31 PM, 9:33 PM, 10:25 PM, 1:15 AM, 2:35 AM, 3:21 AM, and 5:09 AM. In addition, LPN #1 was seen coming back into the building at 4:30 AM but the facility was unable to determine when s/he exited. On 11/10/12, s/he exited the building 12 times that the exit and entrance times could be determined: 7:07 PM, 8:02 PM, 9:10 PM, 10:09 PM, 10:45 PM, 11:03 PM,11:57 PM, 1:21 AM, 2:08 AM, 3:20 AM, 3:55 AM,and 6:49 AM. Additionally, at 4:59 LPN #1 was seen exiting the building. LPN #1 was not seen re-entering the building and was visualized at the dumpster at 6:08 AM and 6:20 AM and re-entered the building at 6:31 AM. On 11/11/12, LPN #1 did not clock in or out per the facility's time line. LPN #1 exited the building at 8:40 PM, 10:19 PM, 11:14 PM, 12:41 PM, 1:28 AM, 1:58 AM, 2:13 AM, 5:41 AM, and 6:20 AM. In addition, LPN #1 was seen on the video entering the building at 6:55 AM but the facility was unable to determine when s/he exited. The facility admitted Resident #18 with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed LPN #2 documented administration of [MEDICATION NAME] 1mg (Milligram) at 3:30 AM. LPN #2 continued to check Resident #18's blood sugar per protocol until it was over 106, at 4:05 AM. On 12/5/12 at 1:15 PM review of the Nurse's Notes revealed a note dated 11/12/12 at 3:30 AM that stated "Resident unresponsive. Blood Sugar check 21 [MEDICATION NAME] 1 mg (milligram) SQ (subcutaneously) (right) thigh monitor BS (Blood Sugar) (every) 5-15 min(utes) 3:45 26, 3:50 53, 3:55 67, 4 AM 90, 4:05 AM BS 106. (Physician) notified Hold [MEDICATION NAME] 500 mg this AM administer 6 PM [MEDICATION NAME] Make sure resident eat" ( documented by LPN #2). The facility admitted Resident #10 to the facility with [DIAGNOSES REDACTED]. Record review on 12/4/12 at 5:43 PM revealed Resident #10 had a BIMS (Brief Interview for Mental Status) of 15, indicating the resident was cognitively intact. The Minimal Data Set (MDS) further indicated Resident #10 required extensive to total assistance with all aspects of Activities of Daily Living except eating. At 10:27 AM on 12/5/12, review of the Resident # 10's Nurse's Notes revealed no documentation by LPN #1 on 11/10/12 through 11/12/12. On 12/5/12 at 11:05 AM, review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On the back of the MAR, in the Nurse's Medication Notes, the administration of the [MEDICATION NAME] was documented on 11/11/12 with no time, 11/12 at 1:30 AM and 11/12/12 at 8:30 AM. The resident's statement on 11/13/12 indicated he/she did not receive the medication at 1:30AM but at approximately 6:15 AM, thus potentially indicating the resident received [MEDICATION NAME] at 6:15 AM and again at 8:30 AM. Review of the admission orders [REDACTED]. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-309 was lowered to a Scope and Severity of "F".

On the days of the Recertification, Complaint and Extended Surveys, based on record review, interviews and review of the facility's files made in reference to a complaint received by this office, the facility failed to effectively utilize resources to ensure that necessary care and services were provided to reduce the residents' risk for harm and that services provided met professional standards. The nurse assigned to Stone Unit left the building multiple times during the 7:00 PM-7:00 AM shift on 11/9/12, 11/10/12 and 11/11/12. On 12-18-12 at 10:35 AM the Administrator was notified that Immediate Jeopardy was Identified at F-490 and that Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12 related to the failure of the facility to provide appropriate care and services. The findings included: On 11/13/12 a report was received by this office from the facility alleging neglect by LPN (Licensed Practical Nurse) #1 who had left Stone Unit multiple times during the 7:00 PM to 7:00 AM shift on 11/9 through 11/11/12. Review of the Five Day Follow-up report received by this office on 11/19/12 revealed Resident #18 was found unresponsive by CNA #1 at approximately 3:00 AM on 11/12/12. The CNA called Rogers Unit and requested the LPN #2 come to Stone Unit. Upon arrival to Stone Unit, LPN #2 obtained a blood sugar which was critically low at 21. S/he initiated the facility's protocol for [DIAGNOSES REDACTED] and stayed on Stone Unit from approximately 3:00 AM until LPN #1 returned at 4:05 AM, leaving Rogers Unit unattended during that time. During an interview on 12/5/12 at 7:58 AM, LPN #2 stated s/he did not call the on-call nurse to report that LPN #1 was not on her/his assigned unit from 3:00 AM to 4:04 AM. During an interview on 12/5/12 at 7:35 AM, CNA #1 stated that s/he told LPN #2 that LPN #1 had "been outside most of the night." S/he further stated that LPN #2 did not respond. In a facility-obtained statement dated 11/14/12, RN (Registered Nurse) #1 indicated s/he texted the on-call nurse "around 2-3 AM" about concerns voiced by the CNAs that they were unable to locate their nurse on Stone Unit. S/he further indicated that "numerous times throughout the night the CNAs were searching for the nurse." During an interview on 12/5/12 at 10:05 AM, the DON (Director of Nursing) confirmed that s/he was the ADON (Assistant Director of Nursing) during that time and that s/he was on call from 7:00 AM on Saturday 11/10/12 until 7:00 AM on Monday 11/12/12. The DON further confirmed receiving a text message that the CNAs were having trouble finding their nurse on Stone Unit. S/he stated that s/he texted LPN #1 and asked where s/he was. LPN #1 responded via text that s/he was in the bathroom. The DON denied receiving any further communication from the staff at the facility related to LPN #1 not being available. On 12/5/12 at 3:30 PM the Administrator stated that all staff had been instructed in the past to call her/him if they don't get an appropriate response from the on call nurse and had provided the cell phone number for them to contact. S/he further stated that s/he couldn't say if the on call nurse's response was appropriate without further investigation. S/he further stated that the CNA had reported on the morning of 11/12/12 at the end of her shift that there had problems over the week-end. S/he further stated that s/he investigated and found that LPN #1 had signed off all the medications and completed the documentation necessary and had not investigated further. S/he was not aware of any problems until Resident #10 reported that he/she had to wait several hours to get his/her medications and that the nurse was not doing her/his job per his/her facility-obtained statement. In addition, the Administrator stated that s/he had reviewed the camera videos only for the time frame of 11/9/12 through 11/12/12. S/he stated that s/he felt that was enough information to terminate LPN #1 and had not reviewed any other time frames. On 12/18/12 at 11:53 AM, review of employee files of 4 Licensed Practical Nurses (LPN) and all Registered Nurses (RN) revealed the facility failed to ensure that all licensed nurses had renewed their licenses prior to the expiration date. During an interview on 12/18/12 at approximately 5:30 PM, the MDS (Minimal Data Set) Consultant confirmed the LPN and RN renewal verifications were not printed until 6/28/12 and stated that all of the renewals were printed at the same time. In addition, the MDS Consultant provided a copy of an e-mail dated 4/30/12 from Human Resources that indicated that 4 nurses had not renewed their licensed as of 4:08 PM on 4/30/12. The 4 nurses included RN "B" and two other LPNs who are still employed at the facility but whose employee files were not reviewed. On 12/18/12 at approximately 4:45 PM, review of the facility's contracts revealed no contract or other agreement with a dentist to provide dental services to the residents of the facility. On 12/18/12 at approximately 4:45 PM, review of the facility's contracts also revealed no contract or other agreement with a laboratory to provide laboratory services to the residents of the facility. During an interview at approximately 5:30 PM on 12/18/12, the Administrator confirmed that the facility had no contract or agreement with a laboratory and further confirmed the facility had not contract or other agreement with a dentist. Cross Refer 483.20(k)(3) F-281 Professional Standards related to LPN #1 leaving her/his assigned unit multiple times during her/his shifts for extended periods leaving Stone Unit unattended by a nurse. In addition, when CNA #1 reported to LPN #1 that Resident #10 who was "yelling" that he/she was in pain, LPN #1 instructed CNA #1 to administer Resident #10's medications, which were in a medicine cup on top of the medication cart while the nurse was out of the building. Cross Refer 483.25 F-309 Quality of Care related to residents being at risk for harm due to the LPN #1 being absent from Stone Unit multiple times during her/his shifts. Resident #18 experienced an episode of [DIAGNOSES REDACTED] with a Finger Stick Blood Sugar of 21 while the LPN #1 was out of the building leaving Stone Unit unattended. The nurse from Rogers Unit responded to the Certified Nursing Assistant's (CNA) request for help, leaving Rogers unit unattended for at least an hour and placing those residents on Rogers Unit at risk while s/he attended to the emergency on Stone Unit. In addition, Resident #10 reported that he/she was in pain and did not receive his/her pain medication for several hours. On 12-18-12 at 10:35 AM the Administrator was notified that Substandard Quality of Care at Immediate Jeopardy was Identified at F-281, F-309, F-490 and F-520. The Substandard Quality of Care and/or Immediate Jeopardy existed in the facility on 11-11-12 related to Resident #11 and Resident #18. Cross Refer 483.55(a) F-411 Dental Services Skilled Nursing Facilities related to the facilities failure to have a contract or agreement with a dentist to provide routine and/or emergent dental services to residents. Cross Refer 483.75(g) F-499 Staff Qualifications related to the facilities failure to ensure that professional staffs' licenses were renewed timely in accordance with state law. Cross Refer 483.75(j)(1)(i) F-503 related to the facility's failure to have a contract with a laboratory to provide services to it's residents. An Allegation of Compliance (AOC) was submitted by the facility. The AOC was accepted on 12/18/12 and after verification that the plan was implemented, the Immediate Jeopardy was removed and the Scope and Severity of F-490 was lowered to a Scope and Severity of "F".